Article Reviews

Staying informed about important studies appearing in the scientific literature can be overwhelming. To help flag significant studies for our members, APIC’s Communications Committee publishes reviews of select articles appearing in the American Journal of Infection Control (AJIC) and highlights the major points that impact the practice of infection prevention. Reviews are published on an ongoing basis. Check this page frequently for updates.

May 2019

Toilet plume aerosol generation rate and environmental contamination following bowl water inoculation with Clostridium difficile spores. Kathleen A.N. Aithinne, Casey W. Cooper, Robert A. Lynch, David L. Johnson. American Journal of Infection Control, May 2019 (Volume 47, Issue 5, pages 515–520) DOI:

Reviewed by Martin Levesque, MPH, MBA, CIC, FAPIC, Detroit, MI

Most, if not all, IPs understand the significance of C. difficile: the burden it places on healthcare, the impact it has on patient safety, and the challenges it poses in controlling infection and preventing cross transmission.  Have you ever wondered if a toilet being flushed after being inoculated with C. difficile, either through patient use, or a healthcare provider rinsing the contents of a bedpan, contributes to environmental contamination?  The authors of this study not only set out to see if C. difficile is aerosolized in the toilet plum, but to what degree environmental contamination occurs.

In order to seed the toilet bowl, the authors used a nonpathogenic strain of C. difficile to create a stock suspension, which was incubated for 10 days, and then heat shocked to kill the vegetative forms. The stock suspension then went through a purification process where the solution was centrifuged, the supernatant removed, and the resultant pellet was resuspended in sterile deionized water. This process was repeated four times. The resultant suspension was then separated into 50 mL aliquots.

The experiment took place in a special water closet that was isolated from the surrounding environment. It was equipped with a flush toilet that flushed 1.2 gallons of water per flush. The room was fitted with an air-tight door, filtered water supply, high-efficiency particulate air (HEPA)-filtered air supply and exhaust, and an outfall to capture flushed water. Prior to all experimental runs, the toilet was cleaned with a standard toilet brush and chlorine bleach solution which was allowed to sit for one hour. After cleaning, the toilet was flushed repeatedly until the free chlorine residual measured less than 0.1 mg/L. Water for this study was public utility water. The authors were also sure to test the toilet bowl and pressure tanks to ensure that the water was not previously contaminated with C. difficile. They used HEPA-filtered air that could be adjusted to provide negative or positive pressure to the surrounding area. Prior to each flush, the air would be purged under positive pressure to remove background aerosol, and then would switch to negative pressure when exhausting C. difficile after a flush. The toilet seat was left in the down position while the lid was left up, which is commonly observed.

The authors then ran a series of three experiments. First, assessing the environmental surface contamination from large droplets generated from the toilet flushing and how long this persisted after the initial flush. Second, aerosol generation from each flush. Third, aerosol generation from each flush followed by purging of the water closet air.

In the first experiment, the toilet water was seeded with the purified C. difficile aliquots. Sterile, inverted culture plates were placed around the toilet. The door was sealed shut and the toilet was flushed. Giving ample time for large droplets to settle, the air was then purged under negative pressure for 30 minutes before the door was opened and the plates collected. New sterile plates were placed, and the door was resealed. The process was repeated for flushes 2–4. Then the process shifted from using sterile plates placed after every flush to having them placed after every fifth flush. This meant that post-flush water and sample plates were collected after flushes 1–4, 9, 14, 19, and 24. This series was then repeated three times in total.

The second experiment used air samplers that were placed one meter high, and .5 meters from the toilet rim. This measures close to sink height where one might leave their toothbrush. The air samplers were started after the door was sealed and the room air purged. The samplers were started five minutes before the first flush. After the first flush, the toilet was flushed every 15 minutes for a total of 12 flushes. After the 12 flushes, the room was purged for 30 minutes under HEPA-filtered negative pressure. The samples were immediately lidded and removed to prevent contamination. This trial was repeated five times.

The third experiment repeated the second experiment but this time the air was purged between flushes. With this experiment, the toilet was flushed, followed by 15 minutes of air sampling. Then, 30 minutes of HEPA-filtered air purge for each flush.

The results of the experiments, in this author’s opinion, rather unsettling. C. difficile colonies were identified on the settle plates through flush 19, but not necessarily on each plate. One to two CFUs (colony-forming units) were typically seen on each plate, with the maximum being four CFUs. The air samplings demonstrated eight, three, and 2.5 CFUs on average respectively. Based on calculations, the authors of the study were able to determine bioaerosol generation of 54, 19, and 17 CFUs per flush respectively. The results from the third experiment were not significantly different than the second experiment.

As a result of these experiments, the authors were able to show that in addition to the contamination of the environment from the first plume generated from the initial flush, persistent contamination occurred with subsequent post-flushing. The air-samples demonstrated that the contamination occurred some distance away from the toilet bowl. Furthermore, the toilet plume generated aerosols that presumably permitted the C. difficile to travel on air currents beyond the immediate toilet bowl vicinity.

These results have significant implications in how environmental contamination with C. difficile can occur. Understanding that an apparently visibly clean toilet can continue to aerosolize C. difficile spores into the environment long after the initial flush changes how we perceive clean. The author believes that organizational housekeeping, isolation, and nursing practices should be reviewed and tailored in light of this study.

APRIL 2019

Kamishibai cards to sustain evidence-based practices to reduce healthcare-associated infections. Shea G, Smith W, Koffarnus K, Knobloch MJ, Safdar N. American Journal of Infection Control, April 2019 (Volume 47, Issue 4, Pages 358–365). DOI:

Reviewed by Beth Wallace, MPH, CIC, FAPIC, Southfield, MI

In the field of infection prevention, we are excellent at implementing practices and bundles to prevent infection.  To this end, there are multiple guidelines and tool-kits available to assist in identification of evidence-based best practices. Once implemented, however, sustainment of these initiatives proves extremely challenging. Infection Prevention often feels like a never-ending game of whack-a-mole, where you think you have finally conquered the animal only to have it pop back up when you turn to another issue. 

In an effort to sustain evidence-based practices to prevent central line associated bloodstream infections (CLABSI) and catheter associated urinary tract infections (CAUTI), a pediatric unit in Wisconsin employed Kamishibai cards (K cards). K cards are performance improvement tools based on a Japanese art form, and have proven successful in other industries. 

Through partnering with Children’s Hospitals’ Solutions for Patient Safety and refinement with nursing leaders, Infection Prevention (IP) developed K cards containing key elements of CLABSI and CAUTI prevention. These cards were further modified based on feedback from front-line staff after implementation. 

K card deployment on the study unit was based on presence of device associated infection risk factors—namely, the presence of an indwelling urinary catheter or central venous catheter. Identification of a patient with an indwelling device prompted the unit-based nursing leader to engage with front-line staff by reviewing K cards. 

K card content consisted of evidence-based bundle measures, and were posed as questions to the staff caring for the patient with the invasive device. For example, “Why does this patient have a central line and is it still necessary?” After questions were asked and answered, the manager reviewed documentation with the patient’s nurse. These interactions allowed for assessment of awareness/understanding of bundle elements, compliance with and documentation of bundle elements, and identification and removal of barriers to ensure staff success. 

K card interactions were scored based on correct responses and compliant documentation of bundle elements, and results were posted centrally to maximize staff awareness. 

While no causal relationship was able to be established, CAUTI rates stayed at zero, CLABSI rates dropped to zero, and utilization of both urinary catheters and central lines decreased during the intervention period.  For other results, staff and leader interviews were conducted, and interviews indicated several benefits of the K card interventions. K cards were noted to remind staff of evidence-based practices as originally intended, but also to facilitate patient and family education and awareness, improve bundle compliance and serve as a real-time audit tool, and allow staff to embrace the role that they play in the prevention of infection. 

Limitations of this study, noted by the authors, included the limited scope (one unit), the fact that only one set of leaders was involved, and the model used to evaluate results. Despite these limitations, K cards may be useful tools to sustain evidence based practices to allow consistent application of efforts shown to reduce infection risks, and warrant further study in the infection prevention arena. 

October 2018

A microbiological study to investigate the carriage and transmission-potential of Clostridium difficile spores on single use and reusable sharps containers. Grimmond T, Neelakanta A, Miller B, et al. American Journal of Infection Control, October 2018 (Volume 46, Issue 10, Pages 1154-1159). DOI:

Reviewed by Cynthia Kohan, MT(ASCP), MS, CIC, FAPIC, Waterbury, CT

The spores of Clostridium difficile (C. diff) can remain viable on hospital environmental surfaces. Thorough disinfection of all environmental surfaces, using a sporicidal product is recommended in order that the surfaces do not serve as a reservoir for transmission to other patients occupying the room. Reusable sharps containers (RSCs), used in many hospitals, items that remain in the room for multiple patients, are considered a high touch surface and have been linked by at least one study to be associated with a higher risk of C. diff acquisition when compared to disposable sharps containers (DSC). This study used a multifaceted epidemiologic, microbiologic, chain of infection, and test of evidence approach to determine if a relationship between C. diff infection (CDI) and sharps containers is feasible. The study attempted to answer three questions. One (Stage 1), Do RSCs carry C. diff upon arrival at processing facilities? Two (Stage 2), Does the decontamination process remove C. diff spores from RSCs? And Three (Stage 3), Do DSCs and RSCs in CDI patient room differ in their carriage rate of C. diff spores? RSCs were cultured upon arrival to the reprocessing facility, RSCs inoculated with C. diff spores, were cleaned using standard plant technology and then cultured to see if any spores remained and both RSCs and DSCs located in rooms with patients diagnosed with CDI, were swabbed. In Stage 1 4.6% of RSCs were positive upon arrival to the reprocessing plant. In Stage 2, no positive RSC was recovered after routine plan wash and disinfection processes were completed. In stage 3, 8.0% of the RSCs recovered C. diff spores while 16% of the DSC recovered spores.

Conclusions from this study noted that DSCs and RSCs both have a low density and low frequency of C. diff carriage, and the carriage of reusable containers are not higher than disposable containers. Like any other patient room environmental surface, daily disinfection with a sporicidal agent is recommended to prevent the transmission of CDI to other patients. Additionally, the proper use of gloves while handling and disposing of sharps as well as proper hand hygiene upon removal of gloves can also decrease the risk of transmission.

Limitations of this study include the impracticality of swabbing a sufficient number of containers to increase the statistical power calculations. The study hospitals were not chosen randomly, nor were there blinded personnel involved in the swabbing. It was felt that how sharps containers are use within hospitals is unlikely to be dissimilar. The authors concluded that it is not scientifically feasible for sharps containers be an effective fomite for C. diff transmission.

September 2018

Rate of contamination of hospital privacy curtains in a burns/plastic ward: A longitudinal study. Shek K, Patidar R, Kohja Z, et al., American Journal of Infection Control, September 2018 (Volume 46, Issue 9, Pages 1019–1021). DOI: 10.1016/j.ajic/2018.03.004 

Reviewed by Marie Wilson, BSN, BS, RN, CIC, Dallas, TX Cleaning and disinfection of the healthcare environment are well-established interventions for infection prevention and control. There is a perceivable lack of guidance specific to privacy curtains, however, which concern some as a source of contamination in semi-private healthcare settings. To better understand the validity of such concern, the study authors utilized a longitudinal, prospective study over a 21-day-period to assess the risk of contamination these textiles hold in the care environment.    Nearly 700 cultures were collected from 10 privacy curtains in a burns/plastic ward over the study period, with two of those curtains being controls. All curtains were assessed for degree of contamination and presence of MRSA through culture-based testing. Mean CFU/cm2 increased 25-fold over the 21-day study period among the eight curtains in patient care areas, while mean contamination among the two controls was significantly less at a 6-fold increase. Half of the curtains sampled from patient care areas had MRSA growth within the first 10-days of use, and the majority within 14-days. Neither of the control curtains grew MRSA during the 21-day study period. The study authors determined both the degree of contamination and the presence of MRSA indicate contamination occurs through direct contact in the patient care environment and perpetuates overtime.    Conclusions from this study illuminate the potential risk high-touch, hard-to-disinfect surfaces, such as textiles, may pose to the care environment, especially when in close proximity to patient care. The study authors point out the lack of standards related to hospital surface hygiene and suggest using standards previously established in other industries, such as food processing, to guide practice. Furthermore, the authors use this pilot study to guide practice specific to privacy curtains in non-private room settings, suggesting replacement occur after approximately 14-days of use.    This study has a small sample size, so more research is needed to determine further consequences of contaminated privacy curtains.  

August 2018

Understanding the patient experience of health care-associated infection: A qualitative systematic review. Currie K, Melone L, Stewart S, et al., American Journal of Infection Control, August 2018 (Volume 46, Issue 8, Pages 936-942). DOI:

Reviewed by Lori Groven, MSPHN, RN, CIC, Bloomington, MN 

When a person thinks of a hospital-associated infection (HAI), often the instantaneous consequences such as hospitalization, medications, and cost come to mind. While literature addresses these impacts during the acute phase of an HAI, little information is available regarding the impact of an HAI on a patient and their families in the immediate and long-term period following an HAI.

The authors of this article examined information on the adult patients’ experience of an HAI during and after hospital admission, the perceived impact of infection on daily living, family relationships, finances, and work and whether the type of infection influences the patient experience. A search of nationally recognized research databases yielded more than 5,000 articles related to the patient experience of an HAI. A thorough quality review, data extraction, and data synthesis of these articles yielded four different themes: continuum of emotional and physical responses to HAI, experiencing the response of healthcare professionals to HAI, adopting to life with an HAI, and the complex cultural context of HAI.

There was significant difference in the range of emotional and physical responses to HAIs among patients. While some patients reported extreme emotional or physical distress others reported minimal distress, regardless of whether physical symptoms were present. The authors noted that there was a key distinction in patient experience between those who had an active infection compared to those who were colonized. They described the effect as “I know” (referring to those with physical symptoms of an infection” compared to the “they say I have” (referring to patients who are colonized without symptoms of an active infection). As one would expect, patients with overt physical symptoms were more likely to report physical and emotional distress. Another indicator noted to have an effect on patient response was the way the information regarding the HAI was communicated to the patient and by whom it was communicated by with less perceived worry noted among patients when the information was conveyed by an infection specialist. 

The quality of interactions with healthcare providers was also noted to have an impact on the patient’s response with recurring themes of not being taken seriously, receiving inadequate information, and feeing stigmatized. This lead to feelings of frustration, over isolation, and confusion with two studies noting the use of “MRSA cards”, which patients had to present at each healthcare encounter, exacerbating existing feelings of stigmatization.

There were also several concerns related to adapting to life with an HAI. Fears of transmission and HAI symptoms that patients perceived as “socially undesirable” lead to feelings of isolation and depression. Concerns about finances and work adaptations were also noted, though data was limited on those aspects.

Patients’ physical and emotional responses must be taken into consideration when communicating information regarding an HAI. Utilizing an infection preventionist (IP) is essential to ensuring the information provided to patients is accurate, consistent, relevant, and patient-centered. Although HAIs are a medical condition to be treated they are also a “socially constructed reality that shapes patient experiences and responses of patients, healthcare providers, and family members.” Additional research to investigate the complex relationship between HAIs and patient responses is needed to inform recommendations for healthcare worker response to patients with HAIs.  

May 2018

A systematic approach to quantifying infection prevention staffing and coverage needs. Bartles R, Dickson A, Babade O, American Journal of Infection Control, May 2018 (Volume 46, Issue 5, Pages 487–491). DOI:

Reviewed by Beth Wallace, MPH, CIC, FAPIC, Royal Oak, MI

Many can relate to the statement “there are never enough hours in the day,” and infection preventionists (IPs) certainly identify with this sentiment. In the last decade, the demands on IPs have increased dramatically with the incorporation of healthcare-associated infections into reimbursement programs, including CMS’s Hospital-Acquired Condition Reduction Program and Value Based Purchasing Program. In addition, as care has expanded beyond the walls of hospitals, IPs are expanding their scope beyond the traditional setting to ensure safe care in all settings. 

The authors of this article set out to account for the rapid expansion of infection prevention and control (IPC) in an updated staffing model. Reviewing existing literature, there are six studies that help define appropriate staffing ratios for IPC programs, the most recent of which was published in 2011, and as such, these sources do not account for the recently expanded scope of IPC. The authors also note concern that existing literature primarily reviews current state, but does not consider the question of how ideal staffing would look.

In reviewing the current state, the authors surveyed all physical locations within their 34-hospital system to include long-term care facilities and ambulatory clinics. Additional care settings such as rehabilitation facilities, compounding pharmacies, etc. were also identified for a comprehensive list of areas with IPC needs. With this list compiled, the authors conducted multidisciplinary meetings with key stakeholders to review the list, and define activities expected in an ideal IPC program. Activities were assigned desired frequencies and estimated duration to calculate IPC full time employee (FTE) needs. 

IPC FTE needs were compared to current staffing models, and three models were developed for the system defining current, better, and ideal states to allow step-wise additions to staffing over time.

When comparing the IPC FTE needs calculated to previously published suggested staffing ratios, prior ratios were 31–66% lower than the quantitative results determined by the authors’ process. Overall, this health system identified a new ratio of 1 IPC FTE per 69 beds, including all settings requiring IPC support.

Staffing models for IPC programs need to be evaluated given the expanded scope of IPs, and this article describes one system’s approach. Given disparate needs and services, it is difficult to apply a one-size-fits-all staffing ratio, but following this process will allow hospitals and health systems to define their own ideal staffing ratio. 

April 2018

Wearing long sleeves while prepping a patient in the operating room decreases airborne contaminants. Markel TA, Gormley T, Greeley D, et al., American Journal of Infection Control, April 2018 (Volume 46, Issue 4, Pages 369–374). DOI:

Reviewed by Angela Vassallo, MPH, MS, CIC, FAPIC, Santa Monica, CA

Surgical attire is a controversial topic in infection prevention. Increased regulatory scrutiny on the use of appropriate surgical attire at the appropriate time has instigated much debate in infection prevention and surgery committee meetings. Surgery staff wearing dangling face masks and booties outside of the OR setting are an unpleasant sight to any rounding infection preventionist (IP). However, when forced to follow up on surgical attire compliance issues with surgical staff, IPs sometimes struggle to find data that support regulatory expectations.

The authors of this study attempt to make sense of one facet of surgical attire in the OR. In this study, they conduct an experiment to determine if wearing long sleeves and gloves while applying pre-operative skin prep reduces the shedding of particles and subsequent dispersal of bacteria on the operating field. The study was conducted from February to July 2017 in one operating room (OR) at each of three different hospitals. Two of the facilities were academic medical center hospitals, and one was an ambulatory surgery center affiliated with a hospital. All three of the ORs had high-efficiency particulate air (HEPA) filtration systems. The study team included a surgeon, a microbiologist, an industrial hygienist, and two engineers. Four experiments were conducted in each of the three OR settings for a total of 12 mock skin prep procedures. Mock skin prep procedures were alternated between “bare arms” and “sleeves” experiments. In the “bare arms” experiments the surgeon who performed the mock skin prep did not wear a long-sleeved gown nor gloves. In the “sleeves” experiments the same surgeon who performed the mock skin prep wore a long-sleeved gown and sterile gloves.

Active bacterial assessment during the mock skin prep procedures involved the use of surface air sampler machines. Particle contamination was measured by placing a particle counter to the right of the bed. The particle counter sampled particles for each minute of the 11 minute mock skin prep time for each experiment. Passive microbial assessment occurred by placing four blood agar plates on the sterile field. New blood agar plates were replaced with each experiment for a total of 48 plates used in the study.

There was no statistical significance found in the particle size for any of the procedures conducted in two of the ORs. However, there was a lower amount of large particle shedding during the “sleeves” procedures in one of the academic medical center ORs. Coagulase negative staphylococcus, micrococcus, and Corynebacterium were the most common bacteria found on the blood agar plates. Micrococcus was found significantly less in the “sleeves” experiments than in the “bare arms” experiments.

Although these findings may come as no surprise, the study had several limitations. First, the mock skin prep procedures were conducted without a real or even a mock patient. This means that there were no humans involved in the mock skin prep practice even though the surgeon conducted a mock skin prep using a chlorhexidine gluconate skin prep applicator. It is unclear how the mock skin prep was conducted or if it was applied to anything. Second, each mock skin prep procedure lasted 11 minutes. This is significantly longer than most actual patient skin prep procedures in OR’s. Third, the study team did not involve an OR nurse nor did it involve an IP. This is significant because OR nurses generally conduct preoperative skin prep on patients. It would have been helpful to have the person, such as an OR nurse, who actually conducts skin prep to perform the experiments instead of the surgeon as most surgeons do not apply preoperative skin prep to their patients. Also, it would have been helpful to have an IP participate on the study team to point out differences of this nature. Despite these limitations, this study can be helpful to IPs when discussing surgical attire compliance with healthcare staff.

March 2018

Leadership rounds to reduce health care-associated infections. Knobloch MJ, Chewning B, Musuuza J, et al., American Journal of Infection Control, March 2018 (Volume 46, Issue 3, Pages 303–310). DOI:

Reviewed by Marie Wilson, BS, BSN, RN, CIC, Dallas, TX

“Go to the Gemba!” This may be a familiar phrase to some, as leader rounding (LR) has grown in popularity over recent years. Quality improvement programs employ LR to drive process improvement and impact patient satisfaction. The philosophy grew out of Toyota’s Gemba Walks, which is the practice of going to where work is happening to understand the current state of practices and tap into frontline staffs’ expertise to problem solve and plan for future state. 

The authors of this study explore the effect of LR on evidence-based practices to reduce hospital- associated infections (HAIs), specifically catheter-associated urinary tract infections (CAUTIs), central line-associated bloodstream infections (CLABSIs), and Clostridium difficile infections (CDIs). Preliminary data indicated initiation of HAI LR positively impacts CAUTI rates, so researchers sought to understand which key thematic characteristics and leader communication techniques drive success.

Researchers included five study units of varying patient populations, staffing, size, and infection rates across two hospitals in Wisconsin to examine the impact of HAI LR. Leader rounds included senior hospital leadership, unit leadership, infection preventionists (IPs), and frontline staff. Meetings were held in busy unit hallways or conference rooms with no formal agenda, and were not in response to recent infections, though, recent infection data and rates were reviewed. 

Several themes emerged from LR based on qualitative observational data. Staff themes identified included staff engagement in problem-solving and a willingness to disclose. These themes relied heavily upon leader themes identified, such as leadership’s support of a learning environment, instead of a punitive approach. Researchers observed that staff were more willing to engage in problem-solving when leaders present exhibited curiosity and engaged staff in reflection and evaluation of processes. 

In addition, this study found LR may promote psychological safety, allowing staff to speak up and promote a culture of continuous quality improvement. A limitation of the study was the lack of physician-presence in LR, which the majority of study participants agreed physicians are often a missing link between guideline recommendations and practice implementation.

HAI LR is a powerful tool to consider adding to the toolbox of quality improvement, especially when seeking to create a psychologically safe culture of quality improvement, which engages employees by encouraging their disclosure of adverse events and ideas on promotion of evidence-based practices.  

January 2018

Hospital Acquired Pneumonia Prevention Initiative-2: Incidence of nonventilator hospital-acquired pneumonia in the United States. Baker D, Quinn B, American Journal of Infection Control, January 2018 (Volume 46, Issue 1, Pages 2–7). DOI:

Reviewed by Beth Wallace, MPH, CIC, FAPIC, Dallas, TX

In recent years, progress has been made in reducing hospital-associated infections (HAIs). With many efforts targeting device-associated infections, significant improvements in HAI incidence have been observed. 

One HAI that has not received much attention is hospital-acquired pneumonia in non-ventilated patients (NV-HAP). There are limited studies addressing how big of a problem NV-HAP is, and a primary objective of this research was to identify the incidence. 

Twenty-one hospitals in the United States participated in this study by reviewing patients with administrative codes indicating pneumonia that was not present at admission. Medical records for these patients were then evaluated using the 2013 pneumonia case definition from the Centers for Disease Control and Prevention (CDC). The study period spanned one year. 

In this study, rates of NV-HAP were determined for each site and ranged from 0.12 to 2.28 per 1,000 patient days. While many pneumonia prevention efforts are targeted at patients in intensive care units (ICUs), most (>70 percent) of the NV-HAP patients were found to have acquired their pneumonia outside of ICU. NV-HAP was identified to have been acquired in all types of hospital units. Pneumonia is also often considered a disease of older patients, but over half of the NV-HAP patients identified in this study were under 66 years of age. This study suggests that all patients are at some risk for NV-HAP. 

Limitations of this study include sampling of hospitals being done by convenience methodology. Use of ICD-9 coding as the initial identification of NV-HAP patients is also a limitation. This study also tried to evaluate interventions that reduce pneumonia including head of bed elevation, incentive spirometry, oral care, ambulation, coughing and deep breathing, but as this was a retrospective study, evaluation of these interventions was limited to chart review. Strengths of this study include being a multi-site review and application of CDC definitions to verify NV-HAP cases. 

NV-HAP is an under-studied HAI, in large part because there are no requirements in the United States to track NV-HAP, and because pneumonia surveillance is a time-intensive process. Additional studies are needed to further define the incidence and impact of NV-HAP.  

December 2017

A national collaborative approach to reduce catheter-associated urinary tract infections in nursing homes: A qualitative assessment. Krien SL, Harrod M, Collier S, et al., American Journal of Infection Control, DEcember 2017 (Volume 45, Issue 12, Pages 1342–1348). DOI:

Reviewed by Timothy Bowers, MT(ASCP) MS, CIC, FAPIC, Vineland, NJ

Infection prevention is a major focus for healthcare, with thousands of individuals suffering from healthcare-associated infections annually, the stakes cannot be higher. Prevention practices have continued to spread outside the walls of the hospitals through various methods including the Agency for Healthcare Research and Quality (AHRQ)’s Safety Program for Long-Term Care, a national preventive program that was implemented from 2013 to 2016 and aimed at reducing catheter-associated urinary tract infections (CAUTIs) across U.S. nursing homes. Hospitals have been tasked with and have made headway in reducing infections, including CAUTIs. Recently those efforts have been formally introduced into areas outside of the acute care setting.

In nursing home residents CAUTIs continue to be one of the top three patient safety concerns with an estimated 12 percent of residents having some type of infection. Additionally, these infections increase the need for antibiotics. The use of antibiotics leads to both resistance and can also lead to untoward effects on patients such as Clostridium difficile infections. These infections cause physical and financial harm to some of our most vulnerable patients. 

Typically, in infection prevention and other areas of healthcare we evaluate the outcome metrics without knowing how it impacted the implementing organization overall. This article is a different take by evaluating implementation of a performance improvement project. The authors set out to, and accomplished, give readers that new perspective in their article on the qualitative assessment of implementing AHRQ’s CAUTI Collaborative. 

Collaboratives in this setting, according to the authors are viewed positively. Areas that the collaborative exceled in were increasing their organizational knowledge of CAUTI and prevention methods, additionally in terms of changing catheter practices and staff empowerment. Those areas are important for program success as well as long lasting change within an organization. Such positive views of the respondents, along with improvement of the CAUTI specific metrics involved in the program indicate AHRQ are an important strategy for providing enhanced expertise outside of the acute care setting.

The assessment also shined light on some of the barriers organizations faced during implementation. Barriers exist for any new practice or change proposal and identifying them ahead of time can reduce the likelihood of abandoning a project before completion. In this article the barriers are familiar to any of those that work in patient safety: Time, logistics, and staff turnover. Planning ahead to address these issues can amplify the impact of these collaboratives.  

The study shows qualitative findings can supplement quantitative data and is an important aspect of patient safety and quality improvement. Collaboratives are an important vessel for diffusing knowledge and practices in many settings and continue to drive improvement in organizations that participate.

November 2017

Working with influenza-like illness: Presenteeism among US health care personnel during the 2014-2015 influenza season. Chiu S, Black CL, Yue X, et al., American Journal of Infection Control, November 2017 (Volume 45, Issue 11, Pages 1254–1258). DOI:

Reviewed by Ratna Rao, MD, CIC, Hyderabad, India

Healthcare settings are known sites for influenza transmission. Compliance with vaccination among healthcare workers is poor, and—as the study found—some healthcare professionals (HCPs) often continue to work while ill. The study was conducted to understand the magnitude of and reasons why HCPs with influenza-like illness (ILI) still report to work, known as presenteeism. 

The researchers used a national nonprobability internet panel survey of HCPs during the 2014-2015 influenza season, calculated the frequency of HCPs who worked with self-reported ILI (e.g., fever and cough or sore throat) and examined their reasons for working with ILI. The study pulled data from HCPs across occupations and work settings. 

In total, 12 probable reasons were offered for HCPs to select why they still came to work despite having ILI. Of these, the survey identified the most common reasons for HCP presenteeism, namely “I could still perform my job duties,” “I wasn’t feeling bad enough to miss work,” “I did not think I was contagious or could make other people sick,” “I have a professional obligation to my co-workers,” and “It is difficult for me to find someone to cover for me.” 

Researchers also found that 44.6 percent of HCP who reported working with ILI received an influenza vaccination, compared with 29.2 percent who were not vaccinated. HCP’s perception about their ability to perform duties and professional obligations reflected a misconception about the risks of ILI to patients and colleagues.

The study’s limitations included: the data from the opt-in internet panel did not stem from a random sample and, thus, the results might not be generalizable to all HCPs. In addition, the sample size was small. The timing of symptoms was unknown. Moreover, symptoms’ severity and duration, factors that might influence the decision to work with ILI, were not directly assessed.

The study suggests that presenteeism with ILI is common among HCPs across occupation and work settings. Clinical encounters are opportunities for medical providers to reinforce recommendations to HCPs to refrain from working with ILI. Also, misconceptions about ILI among HCP must be addressed, including ensuring HCPs are aware of sick leave policies.

October 2017

Impact of an electronic sepsis initiative on antibiotic use and healthcare facility – onset Clostridium difficile infection rates. Hiensch R, Poeran J, Saunders-Hao P, et al., American Journal of Infection Control, October 2017 (Volume 45, Issue 10, Pages 1091–1100). DOI: 

Reviewed by Jessica Silvaggio, MPH, CIC, CSSGB, Los Angeles, CA

Electronic sepsis screening and treatment protocols have been successfully implemented in an effort to improve patient outcomes. Less information is known about the unintended consequences of such programs including nonspecific increases in broad-spectrum antibiotic use and related outcomes including healthcare facility onset (HCFO) Clostridium difficile infections (CDI). This is important because the prevalence of HCFO CDI is increasing with the primary risk factor being broad-spectrum antibiotic use.

The article discusses the main study effects of a sepsis performance improvement program called Strengthening Treatment and Outcomes for Patients (STOP) Sepsis. Hiensch and colleagues evaluated the impact of their electronic sepsis screening program on antibiotic use and CDI rates using longitudinal, interrupted time series data. Segmented regression analysis compared outcomes among three timeframes: pre STOP Sepsis initiative, STOP Sepsis implementation, and post STOP Sepsis initiative). Two measures were of interest: 1) administration of selected broad-spectrum antibiotics in days of therapy (DOT) per 1,000 patient days per month, and 2) HCFO CDI cases per 10,000 patient days per month.

Researchers found that antibiotic use and HCFO CDI rates increased during the implementation and post implementation periods compared to baseline. While the most commonly used broad-spectrum antibiotics were cefepime and levofloxacin (99.9 and 51.1 DOT per 1,000 patient days/ month, respectively), the main drivers of overall antibiotic use were not the antibiotics included in the sepsis order set (ie, cefepime, imipenem-cilastatin, aztreonam). Aligned with the changes in trends of combined antibiotic use, HCFO CDI rates significantly decreased before implementation (-1.4 events per 10,000 patient days/ month), significantly increased during (1.6 events per 10,000 patient days/ month) and post implementation (10.8 events per 10,000 patient days after hospital implementation).

One of the primary conclusions of this study is that the integration of the sepsis initiative coincided with changes in broad-spectrum antibiotic use and HCFO CDI rates in adult patients admitted to medical wards. The use of levofloxacin was the cause of the increase in antibiotic use. Both HCFO CDIs and antibiotic use began to plateau in the post implementation period. While sepsis quality initiatives have been assessed and have found improvements in sepsis outcomes, few studies have been published on the unintended consequences of such programs. Given the observational study design, one cannot assume the STOP sepsis initiative caused increases in antibiotic use and HFCO CDI rates. Of note, changes in antibiotic use and HCFO CDI rates could have occurred independently of the STOP sepsis initiative although confounders like demographic changes or other hospital quality improvement initiatives cannot be excluded. 

September 2017

Transmission of methicillin-resistant Staphylococcus aureus to healthcare worker gowns and gloves during care of residents in Veterans Affairs (VA) nursing homes. Pineles L, Morgan DJ, Lydecker A, et al., American Journal of Infection Control, September 2017 (Volume 45, Issue 9, Pages 947–953). DOI: 

Reviewed by Vicki Allen, MSN, RN, CIC, FAPIC, Gastonia, NC

This is an observational study focused on residents in VA nursing homes colonized with methicillin-resistant Staphylococcus aureus (MRSA) but is applicable to both residents and patients encountered in everyday situations in all types of healthcare facilities across the United States. Highlights point to the everyday practice of healthcare personnel interacting with residents/patients including those basic needs such as bathing and dressing. In this study, the authors define tasks such as general hygiene, dressing and bathing as “high risk,” and other tasks including glucose monitoring, medication administration and feeding are deemed as “low risk” for MRSA transmission. The author’s provide details on estimating the frequency in which MRSA is transmitted from a colonized resident to the gowns and gloves worn by healthcare personnel during their usual interaction with these colonized residents. 

The VA conducts MRSA surveillance on all nursing home residents on admission, at discharge as well as every 6 months. In addition, the VA recommends certain care practices for managing MRSA colonized and infected residents including guidance for managing colonized residents using enhanced barrier precautions. In nursing homes, contact precautions are not as easily maintained due to the home-like environment that is encouraged in this setting. 

The study results are not surprising but they still valuable in identifying the risks associated with the transmission of MRSA via gowns and gloves of healthcare personnel during daily care of MRSA colonized residents. Many times, healthcare personnel question the rationale in isolating colonized patients/residents. This study is an easy read and provides food for thought as organizations consider the use of transmission-based isolation precautions in any setting of which healthcare is delivered. 

August 2017

Clinical and social barriers to antimicrobial stewardship in pulmonary medicine: A qualitative study. Broom J, Broom A, Kirby E, et al., American Journal of Infection Control, August 2017 (Volume 45, Issue 8, Pages 911–916). DOI: 

Reviewed by Ida Lyn E. Benemerito, MSN, BSN, RN, CIC, North Chicago, IL

Judicious use of antibiotics remains challenging in the setting of pulmonary infections. Pulmonary infections represent one of the highest proportion of hospital admissions, inpatient days, and contributes to high rates of antibiotic consumption, which makes for an ideal setting to target antimicrobial stewardship and optimize patient outcomes.

Researchers conducted this study to identify social and behavioral factors that influence antibiotic prescribing practices in pulmonary medicine. This initial study, conducted in two teaching hospitals in Australia, is part of a series in a comprehensive research program involving healthcare professionals and subspecialties. Researchers invited twenty-eight physicians and nurses working in pulmonary medicine to participate in the study, which comprised of semi-structured qualitative interviews. The interviews garnered their experiences with antibiotic utilization and perceptions of antimicrobial resistance.

The study identified clinical barriers. Clinical barriers, specifically with the differential diagnoses for pneumonia versus COPD, viral versus bacterial infections, and colonization and infection proved problematic. These clinical barriers influenced the decision to prescribe antibiotics, contributed to overprescribing, and revealed variations in clinical practice among specialty services.

Research also identified social barriers. Results indicated participants perceived the increase of multidrug resistant organisms was not related to or an immediate threat to current practice, attributing resistance to agricultural practices and suboptimal prescribing practices in other countries. The study also revealed the lack of perceived value with implementing a guideline-based care contrary to individualized care. Furthermore, hospital hierarchal structures influenced antibiotic decision-making.

Limitations of this study include the sample size. Researchers contend the need to conduct further research in different cultural and institutional settings. Researchers also suggest garnering perspectives from other specialties managing pulmonary infections, as well as, the pharmacists’ role in antibiotic prescribing practices.

This study highlights the need for multidisciplinary collaboration to address the clinical and social barriers with antimicrobial stewardship in the setting of pulmonary infections to effectively promote the judicious use of antibiotics.

July 2017

Applying human factors and ergonomics to the misuse of nonsterile clinical gloves in acute care. Wilson J, Bak A, Loveday H, American Journal of Infection Control, July 2017 (Volume 45, Issue 7, Pages 779–786). DOI: 

Reviewed by Peg Pettis, MPA, BSN, CIC, Rochester, NY

Hand hygiene is an important method of decreasing the risk of infection, and infection preventionists are continually reminding healthcare workers to perform hand hygiene. There needs to be increased focus on the use of gloves as recent research find healthcare workers are using nonsterile clinical gloves (NSCG) inappropriately. The researchers of this study feel the impact of the misuse of nonsterile clinical glove use needs to be addressed, and the attitudes and behaviors that influence NSCG use and strategies need to be developed to decrease the inappropriate use of NSCG and improve patient safety.

The researchers observed healthcare worker glove use and found gloves are often applied before any contact with blood or body fluid, such as when handling equipment or bed making. The authors observed that cross-contamination occurred because healthcare workers did not change gloves after or between procedures, such as touching blood or body fluid then touching a patient. Healthcare workers did not perform hand hygiene upon removal of gloves in more than 40 percent of observations.

Interviews of healthcare workers found a variety of reasons for the use of NSCG which fell into two key themes: emotion and socialization. Emotional themes were demonstrated by the healthcare worker feeling the need to protect themselves, examples given by staff were feelings of disgust and uncleanliness and the use of NSCG assisted in depersonalizing care. Socialization themes impacting a healthcare workers decision to wear gloves are influenced by training, peers, and usual ways of working. 

Researchers state the use of gloves were impacted by so many variables that simply educating staff or having a policy would not be successful in changing the inappropriate, widespread use of nonsterile clinical gloves.

May 2017

Merging video coaching and an anthropologic approach to understand health care provider behavior toward hand hygiene protocols. Boudjema S, Tarantini C, Peretti-Watel P, et al., American Journal of Infection Control, May 2017 (Volume 45, Issue 5, Pages 487–491). DOI: 

Reviewed by Jessica Silvaggio, MPH, CIC, CSSGB, Los Angeles, CA

Performing appropriate hand hygiene remains an effective and simple way to prevent healthcare-associated infections. Although this practice has been shown to be effective at reducing the risk of transmitting infectious agents in the healthcare setting, data shows that healthcare providers clean their hands, on average, 50 percent of the times they should. 

In this study, conducted in a medical ward specializing in tropical and communicable diseases in southeastern France, the authors used an anthropological approach conducting in-depth interviews coupled with video coaching to better understand adherence practices and perceptions of hand hygiene. Forty-three video-recordings were selected for review. Among the videos selected, 15 of 20 healthcare providers participated in in-depth interviews where they watched their respective recorded behaviors and were asked to comment on observance of protocols toward hand hygiene (and wearing gloves) particularly when non-compliance was observed. 

Qualitative research findings indicated three thematic pillars:

  • Attitudes toward hand disinfection protocols
  • Glove (ab)use and hybrid practices
  • Risk perception and perceived immunity

A review of the video-recordings showed that healthcare providers frequently were not compliant with hand hygiene protocols and overused gloves. In-depth interviews indicated providers were consciously non-compliant. Although providers displayed knowledge of protocols, they considered the protocols confusing and inadequate. As a result, providers developed hybrid practices to reconcile protocols with constraints in daily practice. Noncompliance with hand hygiene resulted from competing risk and priorities that varied across provider type category (e.g. physician, nurse, therapist, etc.). Researchers found the risk of contamination to be invisible (e.g., not perceptible to the senses) and uncertain (e.g., knowledge about risk is neither complete nor stabilized). Such risk can fuel malleable perceptions and cognitive adaptations including emphasizing one’s personal ability to mitigate or control risk in the healthcare environment. Providers expressed beliefs regarding immunity after prolonged exposure. 

Based on the findings in this study, it is essential to consider a hospital as a complex and hierarchized organization with formal and informal rules. Efforts to improve hand hygiene may be more successful if infection control protocols were adapted to existing practices rather than maintaining unachievable expectations. 

April 2017

Isopropyl alcohol is as efficient as chlorhexidine to prevent contamination of blood cultures. Martinez J, Macias JH; Arreguin V, et al., American Journal of Infection Control, April 2017 (Volume 45, Issue 4, Pages 350–353). DOI:

Reviewed by Vicki Allen, MSN, RN, CIC, FAPIC, Gastonia, NC

Prevention of healthcare-associated infections (HAIs) and patient safety is of primary importance for all hospitals. The pressure to reduce and prevent HAIs is a result of increased focus on these events, which includes public reporting and accountability among payers.

The authors of this study present the case that isopropyl alcohol is as efficient as chlorhexidine in preventing contamination of blood cultures. Infection preventionists are all too aware of the ramifications a positive blood culture presents. First and foremost is the direct effect to the patient, which likely will result in an increased length of stay as well as exposure to antibiotic therapy. For the hospital, such events may be subject to penalty and is publicly reported. False positive blood cultures have the same effects including the additional costs to the hospital and event reporting. For patients, false positive blood cultures can result in not only an increased length of stay but also exposure to and potential resistance to unnecessary antibiotics.

Besides comparing the effectiveness of isopropyl alcohol and chlorhexidine for antisepsis, which is impressive, the focus on the strategies to optimize blood culture collection in an effort to prevent contamination should not be ignored. To ensure success during trials and implementation of new products and processes, strategies cited in this study including personnel training and product selection is very important for hospitals to recognize and adhere to. The explicit training and instructions provided to personnel described in this study likely contributed to the low false positive and contaminated specimen results. These are important points to consider when implementing any new product and /or process.  

This article provides good rationale for hospitals to consider for product selection as well as the importance of education and training of personnel in efforts to eliminate false-positive blood cultures and the potential to decrease operating cost.  

March 2017

Are hospital floors an underappreciated reservoir for transmission of health care-associated pathogens? Deshpande A, Cadnum J, Fertelli D, et al., American Journal of Infection Control, March 2017 (Volume 45, Issue 3, Pages 336–338). DOI: 

Reviewed by Kissa M. Robinson, RN, BSN, MHA, MBA, Capitol Heights, MD

In every issue of the American Journal of Infection Control (AJIC), there is an article that expresses the importance of hand hygiene compliance. Also, there is heavy discussion centered on healthcare-associated organism presence, transmission, and risks. However, there are not many conversations regarding hospital floors and their potential for transferring pathogens to hands. This brief article examines isolation room floor contamination and the possibility for transfer of pathogens from the floor to hands.

In this study, authors conducted a survey to assess patient room floors and high-touch objects on the floor for contamination of pathogens that are potentially spread by hands. Five Cleveland area hospitals were selected and surveyed for patient room floor contamination. Sample cultures were taken from the floor of the hospital rooms and tested for Clostridium difficile (C. diff), MRSA, and VRE. The bare and gloved hands of healthcare workers handling high-touch objects—such as blood pressure cuffs, canes, urinals, and wash basins—from the floor were also cultured. 

The sample cultures revealed that C. diff, MRSA, and VRE were found especially in the CDI patient isolation room. While MRSA and VRE were less likely to be found in a non-isolation room. As well, terminal cleaning after patient discharge, the floor remained to be contaminated with C. diff, but not MRSA and VRE. The samples from the hands, bare or gloved, also showed evidence of contamination with at least one of the three pathogens.

This initial study proves to support that patient room floors are contaminated with healthcare-associated pathogens. As hands remain the number one transmitter of pathogens, this study also implies the possible transfer of pathogens from hands, bare or gloved, that pick up patient care items from the floor. Study limitations noted that testing was limited to the selected pathogens, C. diff, MRSA, and VRE; hospital floor cleaning supplies did not contain spore retarding ingredients; cultured rooms were not identified as having a patient with or without C. diff; and culture methods focused on C. diff versus MRSA and VRE. 

In conclusion, the authors suggest further research opportunities to explore if hospital floors truly add to the transmission of pathogens. While further research is needed, infection preventionists should begin the conversation with their in-house environmental cleaning team. Appropriate cleaning of hospital patient rooms includes the floor. However, how often it should be cleaned and the products to be used for minimizing pathogens is key.

February 2017

Hepatitis C virus transmission in a skilled nursing facility, North Dakota, 2013. Calles D, Collier M, Khudyakov Y, et al., American Journal of Infection Control, February 2017 (Volume 45, Issue 2, Pages 126–132). DOI:

Reviewed by Vicki Allen, MSN, RN, CIC, FAPIC, Gastonia, NC

This study highlights the need for strict infection prevention and control practice in healthcare facilities across the continuum of care. The authors describe lapses in infection control resulting in an outbreak of hepatitis C (HCV) in a skilled nursing facility.

There have been numerous documented outbreaks of HCV in a variety of healthcare settings, however this study describes yet another element of transmission: focusing on the importance of infection prevention and control surveillance and the education of personnel to prevent these outbreaks from occurring. The benefit of having a dedicated infection prevention person is presented well in this study. 

Previous articles have described the transmission of blood borne pathogens such as hepatitis B (HBV), HCV, and human immunodeficiency virus (HIV) via practices such as unsafe injection practice, drug diversion, and inappropriate or lack of cleaning and disinfection of reusable medical equipment. This study describes the largest HCV infection outbreak reported to the Centers for Disease Control and Prevention (CDC) as of 2015. It also describes that if it weren’t for an alert clinician taking the first step to report this outbreak, this event would have continued undetected much longer. Having a dedicated infection preventionist providing education to personnel on all things related to infection prevention such as the epidemiology of important pathogens along with evidence based practice and measures to prevent acquiring and transmitting these pathogens through the appropriate use such things as personal protective equipment, hand washing; cleaning and disinfection of medical equipment and etc. cannot be overstated. 

The authors of this study provide evidence that this outbreak likely occurred through lapses in infection control, therefore highlighting the need to continue and further strengthens the necessity of having a presence of infection prevention and control personnel in healthcare facilities across the continuum of care. 

January 2017

Impact of personalized report cards on nurses managing central lines. Morrison T, Raffaele J, Brennaman L, American Journal of Infection Control, January 2017 (Volume 45, Issue 1, Pages 24–28). DOI:

Reviewed by Barbara A. Smith, RN, BSN, MPA, CIC, FAPIC, New York, NY

Several factors contribute to the development of a central line-associated bacteremias. The authors note that recommended guidelines for insertion have been well described and their impact on CLABS are fairly well documented.

The impact of guidelines for the maintenance of the central venous lines (CVL) is less well studied and this is the focus of this article. This study examines the impact of direct feedback to nursing units and individual nurses when lapses from established maintenance care are noted. 

Using data from prior root cause analyses of the CLABs at their facilities, the authors identified three domains related to care of the central line:

  • Dressing related care,
  • Tubing related requirement, and
  • Documentation.

During a 16-week period, a visual observation of the line and a chart audit was conducted on more than 600 CVLs. Nineteen percent of the CVLs failed to meet one or more of the contributing factors. 

The authors used this data to create unit-based reports and nurse specific reports. The reports included pertinent educational or policy material. Using this approach, the authors demonstrated a significant decrease in the number of lapses in maintenance technique. They also share nurses’ comments familiar to many of us when asked about lapses in care: “I knew the dressing was wrong, but they didn’t change it on the last shift.”

The authors note a decrease in the CLABs rate in the critical care units and a decrease in the absolute number of CLABS from 18 to 10 in the medical surgical units. 

Based on these results, the organization added training for new hires on CVL care, a computerized training course and changes in the electronic medical record. 

December 2016

Safety and Utilization of Peripherally Inserted Central Catheters versus Midline Catheters at a Large Academic Medical Center. Xu T, Kingsley L, DiNucci S, et. al. American Journal of Infection Control, December, 2016 (Volume 44, Issue 12, Pages 1458—1461).  DOI:

Reviewed by Cynthia Kohan, MS, CIC, FAPIC, Waterbury, CT

This study compares the safety and utilization of the peripherally inserted central catheter (PICC) vs. a midline catheter. In an effort to decrease the rate of central line associated blood stream infection (CLABSI) development, many hospitals are attempting to decrease the use of central access devices. Midline catheters are not centrally placed but can provide safe access to infuse many of the same medications. PICC lines are recommended over midline catheters for the infusion of chemotherapeutic agents and when an infusion is likely to exceed 14 days. 

The object of the study was to determine if a midline catheter can be used in place of a PICC to not only reduce an institution’s CLABSI risk, but also provide the same therapeutic value of a PICC without an increase in complications. 

A retrospective study was conducted at a single large university medical center. A chart review was conducted on 206 PICC insertions and 200 midline catheters, placed in 367 patients within the time period of January to May, 2015. In addition to demographic data, data on complications related to the catheter was collected. These included: 

  • Discontinuation related to a non-patent vessel
  • Dislodgement
  • Catheter fracture 
  • Leaking catheter
  • Pain or edema at the insertion site
  • Discontinuation of the catheter due to infiltration, phlebitis or infection
  • Deep vein thrombosis
  • Readmission because of an issue related to the PICC or midline
  • Positive blood culture

The Charlson Comorbidity Index (CI) and intensive care unit (ICU) location when the catheter was inserted was also determined for each patient. 

A total of 17 complications in 12 PICCs and 44 complications in 39 midline catheters were noted. Although the midline was more likely to be associated with any complication, the rates of severe complications were similar between the PICC and midline. Risk stratifying the results utilizing the Charlson Comorbidity Index and whether the catheter was placed while the patient was in an ICU noted that the risk of any complication was more likely in the midline group whether inserted in the ICU or in areas other than the ICU. More complications were also related to midline catheters in both the high and low CI score patient groups. However, the risk of a severe complication was no different in the PICC group vs. the midline group in any care setting or either CI group. 

There were five positive blood cultures reported from the PICC group and five from the midline group. Two of the five cultures in the PICC line group met the NHSN CLABSI definition and were reported as such. None of the positive blood cultures in the midline group were thought to be directly related to the midline catheter. 

Although the midline catheter was associated with more total complications and readmissions, none contributed to the institution’s CLABSI rate. The authors postulate that since the increase of complications in the midline group were non severe, the midline catheter might be a reasonable substitution as institutions move away from the use of central lines to avoid reporting a CLABSI. 

Surveillance of complications was limited to the patients inpatient stay and may have missed occurrences in the outpatient setting. The authors conclude that midline catheters are an acceptable alternative to PICCs despite the increased risk of a non-severe complication, to reduce the occurrence of CLABSI.

November 2016

The behind-the-scenes activity of parental decision-making discourse regarding childhood vaccination. Gesser-Edelsburg A, Walter N, Shir-Raz Y, et. al. American Journal of Infection Control, November, 2016 (Volume 44, Issue 11).  DOI:

Reviewed by Angela Vassallo, MPH, MS, CIC, FAPIC, Los Angeles, CA

Does your facility struggle with healthcare worker vaccination rates? Does the community in which your facility resides struggle with the vaccination rates of its school-aged children? Does your facility treat pediatric patients? Vaccination rates are an important topic for infection preventionists, especially in regards to the role they play in herd immunity. Yet despite what might seem like a simple decision, some parents find the decision to vaccinate their children quite complex. Thus, the researchers in this article took a new approach to understanding parental decision-making by assessing the private discourse between parents at home in regards to vaccinating their children. In particular, the researchers examined whether there were disagreements between parents surrounding childhood vaccination and how these disagreements were resolved.

The study was conducted through an online questionnaire to a diverse group of parents in Israel from December 22, 2015 to April 4, 2016. The target population (N=437) included Jewish and Arab parents (Hebrew and Arabic speaking) of children younger than 14 years of age. The survey was distributed through Google Docs and three different social media outlets (Facebook, general online forums for parents, and Whatsapp).

The target population was divided in to three different parental groups based upon their response to a multiple-choice question about childhood vaccination schedules in Israel:

  • Pro-vaccination
  • Anti-vaccination
  • Hesitant

The survey asked if the parents followed the Israeli childhood immunization schedule. A response of “yes” placed them in the pro-vaccination category, a response of “no” placed them in the anti-vaccination category, and parents who responded with an intermediary response, “for some children and not for others,” “for some vaccines and not for others,” and “I support vaccines but not the schedule,” were grouped as hesitant.

The findings were quite interesting. Hesitant parents were four times more likely to have intrafamily discourse about vaccinations in comparison to the pro-vaccination parents. Hesitant parents were also four times more likely to report intrafamily disagreements than pro-vaccination parents and twice as likely to report disagreements as anti-vaccination parents. Consequently, each group believed that their decision-making process was the social norm. In other words, pro-vaccination parents believed that vaccinating their children was the norm, and so on. The decision-making process and sources used to find information about vaccines was quite different between each of the three groups. Pro-vaccination parents chose doctors and nurses as their most trusted sources for vaccination information. Anti-vaccination parents chose anti-vaccination websites as their most trusted sources for vaccination information. Hesitant parents were the most likely to review scientific literature to get more information about childhood vaccination before making their decisions.

This article illustrates that we must understand private discourse and its role in decision-making in order to improve communication about vaccination. Vaccine risks and outcomes must be communicated to all groups: pro-vaccination, anti-vaccination, and hesitant.

October 2016

Evaluating the effectiveness of ultraviolet-C lamps for reducing keyboard contamination in the intensive care unit: A longitudinal analysis. Gostine A, Gostine D, Donohue C, et. al. American Journal of Infection Control, October, 2016 (Volume 44, Issue 10, Pages 1089-1094).  DOI:

Reviewed by Barbara A. Smith, RN, BSN, MPA, CIC, FAPIC, New York, NY

Do your nurses claim their “work stations on wheels” with their names because they know they will keep it cleaner? Do your unit secretaries guard their work areas because they don’t want other staff “contaminating” it after they’ve diligently disinfected the computer and counter top? If you’ve looked at the computer keyboards and mice on any given unit, they can be sorely lacking in cleanliness. We’re often asked: “Who is supposed to clean them?” “What product should I use?” and “How often should I clean it?” This article suggests that ultraviolet (UV) disinfection might help us address these challenges.

The study examines the impact of UV-C disinfection of keyboards and mice in two intensive care units (ICUs), covering 40 workstations. Automated UV lights were installed on keyboards. Once programmed, the system is designed to turn the UV light on and off automatically, completely independent of activation by the ICU staff.

The authors acknowledge that patients’ respiratory or gastrointestinal flora contribute to transmission of infections but stress that the inanimate environment is increasingly recognized as an important vector of cross-contamination. One study cited that nurses’ hands were equally contaminated after touching a patient as they were after touching surfaces in the room. They note studies demonstrating reduction in healthcare-associated infections (HAIs) when UV disinfection is used for terminal cleaning of patient rooms.

The authors set out to achieve two targets:

  1. Demonstrate that the UV-C disinfection reduced microbial contamination of the keyboards/mice.
  2. Determine the optimal disinfection cycle and frequency that would not interrupt patient care or exceed safety limits.

The authors collected pre disinfection cultures, adjusted the timing and frequency of the disinfection cycle and collected post disinfection cultures. 

Of the more than 200 baseline cultures, 95 percent revealed bacteria growth including Staphylococcus, Pseudomonas, and Klebsiella. After the UV disinfection, 94 percent of the keyboards/mice had no bacterial growth. The colony count on 3 percent of the remaining items was greatly reduced. 

The authors felt they met their goal of a 99 percent reduction in growth with all safety measures satisfied. The authors do not report the impact on HAIs on these two units, but perhaps we can expect a future article from these authors on that subject.

September 2016

Persistent racial and ethnic disparities in flu vaccination coverage: Results from a population-based study. Almario CV, Folasade MP, Maxwell AE, et. al. American Journal of Infection Control, September, 2016 (Volume 44, Issue 9, Pages 1004-1009).  DOI:

Reviewed by Kissa Robinson, RN, BSN, MHA, MBA, Washington, DC

Annually, we see campaigns strongly recommending flu vaccination for all. However, there still remain a great number of individuals that decline being vaccinated against the flu. This article examines racial and ethnic disparities with receiving flu vaccination.

The Advisory Committee on Immunization Practices (ACIP) conducted a retrospective cross-sectional study using public data from the 2011-2012 California Health Interview Survey (CHIS), a population-based telephone survey. The survey is conducted every other year by the UCLA Center for Health Policy Research. The ACIP selected the CHIS because it captures health data for all ages. The telephone survey, available in six different languages (English, Spanish, Mandarin, Cantonese, Vietnamese, or Korean), was randomly sent to landline and cell phones. The population-weighted sample of 27,796,484 included all individuals 18 years and older but excluded adults living in group settings.

The main goal of the study was to identify the individuals that received a flu vaccination within a year. Then they looked at the race and ethnicity of those individuals. The study reveals that the highest rates of vaccination were seen in Koreans, Vietnamese, Japanese, and whites, while blacks and Latinos rated the lowest in receiving the flu vaccination. Although impact of race and ethnicity was the focus, the study noted “chronic condition, graduate degree, insurance, usual source of care or recent doctor’s visit” as reasons why people obtained the flu vaccination. The study also showed that blacks were less likely than whites to be vaccinated against the flu, which is an ongoing disparity. Blacks were less likely due to fear about getting the vaccine and its effectiveness. Whereas, in the study Latinos were vaccinated at a similar rate as whites but various barriers (access to insurance and care) prevented vaccination.

The authors identified the following limitations: the sample only included the California population; CHIS data is self-reported and may not be accurate due to “recall bias;” the study did not consider feelings about preventative care or cultural and religious beliefs from the survey; unable to remove those not able to get the flu vaccination; and data from those living in group settings were not included.

In conclusion, the authors found evidence of racial and ethnic disparities in flu vaccination but there was no difference from the national data as it relates to blacks having lower vaccination rates than whites. As we approach the flu season, infection preventionists should begin the conversation on “uptake of flu vaccination.” Individuals need to be educated in flu vaccination with an emphasis on getting the public to understand how the vaccination works.

August 2016

Enhancement of hand hygiene compliance among health care workers from a hemodialysis unit using video-monitoring feedback. Sánchez-Carrillo LA, Rodríguez-López JM, Galarza-Delgado DA, et. al. American Journal of Infection Control, August, 2016 (Volume 44, Issue 8, Pages 868-872). DOI:

Reviewed by Peg Pettis, RN, MPA, CIC, Rochester, NY

It is refreshing to review facilities efforts to improve on their hand hygiene program using technology. There has been limited research on hand hygiene compliance in hemodialysis units. A review of the literature illustrates how hand hygiene compliance rates vary ranging from a rate of 11.5–57.4 percent employing the usual methods: self-reporting or direct observation.

A hemodialysis unit in Mexico conducted a three-phase longitudinal intervention study looking at hand hygiene compliance over a four month period. In addition to utilizing the direct observation method this study also used video recording to monitor hand hygiene performance. The first phase involved the installation of two video cameras in the 15-bed hemodialysis department, all staff in the hemodialysis unit were aware of the video camera. Following the video installation no hand hygiene monitoring was conducted for two months.

In the next phase hand hygiene compliance was conducted via direct observation and by video camera for four consecutive weeks. The hemodialysis staff assembled and were shown video examples of hand hygiene compliance and non-compliance. In addition, individual reports were given to each staff member, and an over-all report was given to the head of the unit. 

The second feedback session was conducted similar to the first but education on the WHO 5 Moments of Hand Hygiene was also included.

The results comparing the two methods of monitoring hand hygiene compliance varied widely: direct observation reported rates of 57 percent, 65 percent, and 73 percent for the preintervention, first, and second interventions respectively. Video surveillance reported rates: 21 percent, 34 percent and 50 percent. The average improvement in hand hygiene compliance was 30.6 percent.

This study had several interesting conclusions: direct observation may not be the best method of monitoring hand hygiene compliance and “video-assisted monitoring offer a more precise method of evaluating hand hygiene compliance.” Most notably the video camera determined the hemodialysis staff consumed between 22–44.3 percent of the work day performing hand hygiene.

July 2016

Learning from the patient: Human factors engineering in outpatient parenteral antimicrobial therapy. Keller SC, Gurses AP, Arbaje AI, et. al. American Journal of Infection Control, July, 2016 (Volume 44, Issue 7, Pages 758-760). DOI:

Reviewed by Timothy Bowers, MT(ASCP) MS, CIC, FAPIC, Vineland, NJ

As infection prevention goes, seldom does anything happen in a vacuum. There are people, processes, products, procedures, protocols… the list goes on. The belief (and investigations that conclude) incidents occur due to one bad act is increasingly rare, and errors or failure to keep a patient safe is viewed in the context of system in which care is given. Within that context, human factors engineering is an increasingly important part of the infection prevention skillset. “The scientific discipline concerned with interactions among humans and other elements of a system” is a field that in a structured way looks at the potential for harm in that context of care. This commentary from the Armstrong Institute and Johns Hopkins School of Medicine utilizes this skillset outside the walls of the hospital.

The subject of the study, outpatient parenteral antimicrobial therapy, is a great way to prevent patients from unnecessary hospital stays, and as identified has some safety concerns for the patients and/or care givers at home. The level of training for those caring for intravenous access is, typically, not nearly the same. In addition to the level of training, the volume of trained individuals are different. In a hospital or similar setting there are nurses, aides, and doctors all with watchful eyes focused on the care of the patient’s central line and IV, whereas at home it is just you and maybe a family member. The setting from an environmental standpoint is not as regulated as the hospital setting as well. 

The authors applied human factors engineering to this atypical scenario. It is atypical as this science is usually associated with our CUSP (Comprehensive Unit-based Safety Projects) or Team STEPPS (Strategies and Tools to Enhance Performance and Patient Safety) initiatives for CAUTI, CLABSI, SSI, or other inpatient safety programs. In looking at the system the authors listed five specific ways the system could cause harm. The authors did not list all potential failures but showed the scope of investigation as it relates to evaluating the system of outpatient parenteral antimicrobial therapy. As systems are a living breathing entity an exhaustive list of potential failures is not a static list but must be evaluated and reevaluated over time. The five listed failures though are generalizable and meaningful enough to be considered adequate, in my opinion, to serve as examples for the human factors engineering process.

In addition to listing the system failures, the risk factors which exist in the system that could cause that failure are identified. As we are looking at a system there should be multiple risk factor in this step. The authors correctly identified the major three or four broad categories, and for each category has listed at least one potential intervention.

This study shows us the tools we use for infection prevention in the acute setting to improve standard reporting metrics have the ability to be used in other settings as well. This commentary develops the framework for others to study infection prevention interventions in nontraditional settings or metrics using human factors engineering. 

June 2016

Implementation of directly observed patient hand hygiene for hospitalized patients by hand hygiene ambassadors in Hong Kong. Cheng VC, Tai JW, Li WS, et. al. American Journal of Infection Control, June, 2016 (Volume 44, Issue 6, Pages 621-624). DOI:

Reviewed by Barbara A. Smith, RN, BSN, MPA, CIC, FAPIC, New York, NY 

With so much focus on the hand hygiene practices of healthcare workers, it was refreshing to read this article from the authors from Queen Mary Hospital about their efforts to encourage patients to cleanse their hands. 

Having previously published results that demonstrated reduced risk of acquiring MDROs through a directly observed hand hygiene program, the authors sought to expand the program. The initial program was an educational program directed to patients. Each patient received a pamphlet, signs were posted at all bedside, and sanitizers were placed in proximity to the patient. Similar to the WHO Five Moments for Hand Hygiene, the authors defined Three Moments when patient should cleanse their hands: 1) before meals and medications, 2) after bedside bedpan or urinal use and 3) after toileting in a bathroom. The infection prevention team conducted observational audits to monitor compliance with patient self initiated hand hygiene. Overall compliance with patient initiated hand hygiene was 37.5 percent. The authors stratified the results by type of activity with 89 percent compliance with hand hygiene after toileting in a bathroom.

An ambassador assisted hand hygiene program was introduced on 44 units that cared for medical, surgical, ob/gyn, and orthopedic patients. Ninety six front line staff—health care assistants—were trained for this role. They received special recognition from hospital leaders as well as a formal certificate. The ambassadors actively delivered sanitizers to conscious patients before medications and meals and observed them performing hand hygiene. 

Using this method, the overall compliance increased to 97.3 percent. The data analysis included key factors that might increase the risk of MDROs, including presence of invasive devices and antibiotic use, as well as patient related characteristics such as age and comorbidities. While the authors would like to extend the directly observed hand hygiene to all three moments, manpower resources limit the ambassadors program to before medications and meal times. 

The authors acknowledge that the audit process varied between the two phases in an effort to eliminate bias. Although they did not comment on any impact on incidence of MDROs or healthcare-associated infections, this program would likely have a positive impact on patient satisfaction.

May 2016

Risk of infection following colonization with carbapenem-resistant Enterobacteriaceae: A systematic review. Tischendorf J, de Avila R, Safdar N. American Journal of Infection Control, May, 2016 (Volume 44, Issue 5, Pages 539–543). DOI:

Reviewed by Ida Lyn E. Benemerito, BSN, RN, CIC, North Chicago, IL 

The emergence of carbapenem-resistant Enterobacteriaceae (CRE) is a global healthcare challenge that requires targeted strategies to prevent infection of this pathogenic organism. CRE is considered highly resistant and associated with increased morbidity and mortality (up to 50 percent). Tischendorf, de Avila, and Safdar conducted a systematic review of 10 observational studies that comprised of 1,806 adult inpatients colonized with CRE. The study revealed CRE colonization portends the risk for CRE infection. Out of 1,806 CRE colonized adults, 299 developed infections for a cumulative rate of 16.5 percent. Report from quantitative data of 223 colonized patients indicated the following sites of infection:

  • Pneumonia, clinical syndrome (50 percent)
  • Urinary tract infections (20 percent)
  • Primary bloodstream (13 percent)
  • Skin and soft tissue, including surgical site infections (7 percent)

Adverse outcomes associated with CRE colonization or infection is an estimated two-fold increased length of stay. Mortality rate of infected and colonized patients was reported at 10 percent. In three studies, mortality rates increased to 30–75 percent with clinical infection. Some of the contributing factors to high mortality rates include increased length of stay, site of infection, and comorbid conditions. Of great significance are the limited available options of antimicrobial treatment due to the emergence of panresistant Enterobacteriaceae, emphasizing the urgency to develop new antibiotics to combat these organisms. 

Implications for practice are identification and eradication of colonized patients to prevent and reduce the risk for CRE infection. New studies on decolonization demonstrate modest results warranting further large scale studies in outbreaks and endemic settings. The article recommends conducting prospective research on the utility of routine, wholehouse surveillance for CRE in hospitalized patients. It also recommends determining strategies to eliminate CRE colonization.

The authors addressed the limitations of the study. First, there were inherent limitations from the 10 observational studies included in their systematic review. Second, heterogeneity in their study method and population confounded the study. Third, limited data did not allow for analysis of risk factors for CRE infection and mortality. Fourth, the study is predisposed to concerns of misclassification due to the lack of a standardized method for identification of colonization and infection. Lastly, the authors report susceptibility to publication bias. 

April 2016

Using medical student observers of infection prevention, hand hygiene, and injection safety in outpatient settings: A cross-sectional survey. Thompson D, Bowdey L, Brett M, et. al. American Journal of Infection Control, April, 2016 (Volume 44, Issue 4, Pages 374–380). DOI:

Reviewed by Laura Buford, RN, BSN, CIC, Austin, TX 

The University of New Mexico, School of Medicine and the New Mexico Department of Health had second year medical students assess infection prevention policies and practices in outpatient healthcare settings. The study, conducted in summer 2014, evaluated practices in 15 outpatient settings across New Mexico, both rural and urban. The settings were private group, private solo, hospital-affiliated, federal facilities (e.g., Veteran’s Administration or Indian Health Service), state facilities, and one unclassified practice. 

The objectives were to have “medical students understand minimum expectations for safe care and infection prevention in the outpatient setting, assess infection prevention policies and practices, and identify infection prevention educational and quality improvement opportunities within a clinical setting.” The students used standardized data collection tools. Their findings were not surprising.

For the infection prevention review, there were 14 topic areas with 92 subelements including facility policies, general infection prevention education and training, occupational health, hand hygiene, surveillance and disease reporting, and point of care testing. Fifty-three percent of the 92 sub elements had 100 percent compliance. Examples of the ones below 100 percent compliance were annual respiratory fit testing (58 percent), TB screening upon hire and annually (64 percent), and system in place to track which instrument was used on a patient for each procedure (50 percent). 

Injection safety had 163 observations at 14 sites (one facility was excluded due to lack of sufficient injection practices) and found that 66 percent of the time all the recommended injection safety elements were followed. Missing elements included hand hygiene prior to preparation (missed 29 times), rubber septum not disinfected prior to entering medication vial (missed 33 times), and new needle and/or syringe used (missed 8 times). 

Hand hygiene observations had the least surprising results. Observations were of entering and exiting the patient room and preparing medications. Alcohol-based hand rubs were used 34 percent of the time, soap and water 29 percent, and 37 percent of the time there was no hand hygiene done. 

My favorite part of the study was the quality improvement recommendations made by the medical students. Examples of key recommendations were adding more alcohol hand rub dispensers in rooms, in the halls, and by medication prep areas; adding signs to the waiting rooms for respiratory hygiene; placing hand hygiene posters in the offices; and conducting formal cleaning demonstrations to ensure proper staff cleaning of the rooms. 

I hope this group will follow up with these medical student evaluators as they start their own practice to see if they are using the infection prevention information they learned during this study. 

March 2016

Visitor characteristics and alcohol-based hand sanitizer dispenser locations at the hospital entrance: Effect on visitor use rates. Hobbs M, Robinson S, Neyens D, et al. American Journal of Infection Control, March, 2016 (Volume 44, Issue 3, Pages 258-62). DOI:

Reviewed by Vicki Gillie Allen, MSN, RN, CIC, Huntersville, NC 

This article explores one of the most effective infection control measures to prevent the transmission of pathogens—hand hygiene. It also offers a new twist in that the focus of this paper is on the effort to assess the compliance for hand sanitizing of visitors upon entry into the hospital setting. 

Research on hospital visitor hand hygiene is limited, but previous studies indicate observed compliance to this practice being less than one percent. The author also cites studies that suggest that placement and location of hand hygiene dispensers along with visual aids may influence the use for hand hygiene sanitizers. One study cited found that hand hygiene practice was highest at the hospital entrance and yet another found the location of dispensers along with instructions prompting hand hygiene at the hospital entrance was influential in improving visitor hand hygiene. 

Location of dispensers and hand hygiene supplies is a long known environmental barrier in hospitals. Poor product placement and access decreases compliance for healthcare workers to appropriately practice good hand hygiene. Continued and on-going assessment for the location of dispensers and availability of supplies should be a priority for infection preventionists during environmental rounding and surveillance. Knowing placement of dispensers and supplies can be a barrier for good and appropriate hand hygiene, it only makes sense that this could also be a factor and should be considered when educational efforts for performing hand hygiene and keeping patients safe is directed to family members and visitors

This paper suggest numerous ideas and opportunities for hospitals to assess the general rate for hand hygiene compliance for visitors entering the hospital and could very well lead to best strategies for partnering with visitors and families in continued efforts to improve the safety for our patients. 

January 2016

Reducing infection transmission in the playroom: Balancing patient safety and family-centered care. Ivany A, LeBlanc C, Grisdale M, et al.  American Journal of Infection Control, January 2016 (Volume 44, Issue 1, Pages 61–65). DOI:

Reviewed by Barbara A. Smith, RN, BSN, MPA, CIC, New York, NY 

This article discusses practices related to sibling visiting in pediatric playrooms. This is a timely article for the cold and flu season. It is also useful that the authors examined a ritual practice— not allowing visitation—while a relatively simple process can increase safety for patients and their families.

Sibling visits is consistent with practicing family centered care. Citations regarding the benefits of family centered care enhancing physical and emotion well-being of children are noted. Both the American Academy of Pediatrics and the Centers for Disease Control and Prevention (CDC) support sibling visits but only with their own sibling, not in a communal setting such as a playroom.

However, there is scant literature on allowing children to visit their siblings in the playroom and the authors recognized that their facility—a tertiary care hospital in Canada—did not have a formal process for it.

Using an S-B-A-R approach, a quality improvement project was developed involving nurses, unit staff, child life specialists and the infection preventionists. Their objective was to create a system that would maximize sibling visitation yet minimize communicable disease transmission.

The project included four key components:

  1. A literature search on the topic of sibling visitation identified 19 articles although none of them specifically discussed siblings in the playroom.
  2. They queried the 24 IPs from the Pediatric and Neonatal Interest Group of Infection Prevention and Control Canada. The current policies and practices of five pediatric centers were included. Their practices included three centers that allowed playroom visitation but with varying levels of screening for communicable diseases and two additional centers that allowed visitation with formal screening. 
  3. They developed and implemented a screening tool that was completed by the parents/guardians after receiving education by the nurse or child life specialist. 
  4. They evaluated the results of 42 screening that were collected during a two-year period.  The results showed that nearly 10 percent of siblings had potentially communicable illnesses—the majority of which were respiratory in nature. 

The authors acknowledge these limitations:

  1. A small number of screenings. 
  2. No formal evaluation of transmission of illness either before or after the tool was implemented.

The authors expect to expand the use of the process to allow visitation in the playrooms. They also noted a secondary gain that it encouraged more collaboration among the various staff members, particularly in their awareness of infection prevention practices. 

November 2015

The role of message strategy in improving hand hygiene compliance rates. Taylor RE. American Journal of Infection Control, November 2015 (Volume 43, Issue 11, Pages 1166–1170). DOI:

Reviewed by Margaret (Peg) Pettis, MPA, BSN, RN, CIC, Rochester, NY

Hand hygiene has been recognized for many years as one of the easiest and best methods of reducing the spread of infection. Healthcare workers know when to wash their hands and how to clean their hands. Hand sanitizer is provided throughout healthcare facilities, and there have been numerous endeavors to increase hand hygiene compliance rates: songs, videos, posters. However, even with these efforts the hand hygiene rates among health care workers remains low. 

The author of this article feels that one explanation for the low hand hygiene compliance rates may be related to message strategy. “Message strategy refers to a guiding approach to a company’s or institution’s promotional communication efforts for its products, its services or itself.” The idea that one message will resonant with everyone is not true. You cannot give the same message to everyone. 

There are several models used to in an effort to try and change healthcare workers behavior. Some theories believe that providing information will influence behavior. Other theories propose that behavior is emotion-driven. 

Our author reviews a different theory, the theory that there are two persuasive methods of messaging. This messaging theory is described as a circle; the right side of the circle is labeled “transformational” and the left side is labeled “rational.” Transformational communication is directed to the emotional side of people, messages would appeal to one’s beliefs, attitudes, and self-image. Rational communication imparts knowledge and information and would appeal to one’s cognitive or logical side. In addition, behaviors that are less important to the individual are on the bottom of the circle, and items that are more important are on the top.

The author feels “there are at least six paths to persuasion, and there may be different paths for different people under different contexts.” To relate this to hand hygiene: One person may be motivated to wash their hands because they want to protect their family whereas another healthcare worker performs hand hygiene because it is the professional thing to do.

The results of the study substantiates the idea that providing a variety of messaging and rotating the messages throughout the health system may be instrumental in increasing hand hygiene compliance. 

October 2015

Questionable validity of the catheter-associated urinary tract infection metric used for value-based purchasing. Calderon LE, Kavanaugh KT, Rice, MK. American Journal of Infection Control, October 2015 (Volume 43, Issue 10, Pages 1050–1052). DOI: 

Reviewed by Cynthia Kohan, MS, CIC, Waterbury, CT

It is estimated that catheter-associated urinary tract infection (CAUTI) is one of the most common hospital acquired conditions projected to occur in U.S. hospital patients annually and is a component of the Hospital Acquired Condition (HAC ) value based purchasing. Beginning October 2014, hospitals are penalized one percent of their Medicare fee schedule if their performance is ranked in the lowest quartile for the prevention of HACs. This study examined two government metrics related to the occurrence of CAUTI, the CDC’s National Healthcare Safety Network (NHSN) and the Agency for Healthcare Research and Quality (AHRQ) and compared the results from each network. 

The CDC/NHSN metric is self-reported and converted into a standard infection ratio (SIR) whose denominator is the number of catheter days while the numerator is the number of CAUTI identified. The ratio is then adjusted for the various factors including unit type, unit size, and whether the hospital is considered a major teaching facility. The AHQR metric is derived from the medical record review of 18,000—33,000 randomly selected medical records per year from patients diagnosed with myocardial infarction, heart failure, pneumonia, and major surgical patients. These are abstracted from 800 randomly selected CMS participating hospitals. The denominator is hospital discharges while the numerator is the number of CAUTI identified. 

Analyzing the results from the two government systems show discordant results. In the NHSN system, a three percent increase in CAUTI was identified when comparing results from the 2009 baseline SIR to the 2012 data, and a six percent increase when comparing the 2009 SIR with the 2013. THE AHRQ outcome data shows a 28.2 percent decrease in CAUTI between the years 2010 and 2013. One government outcome monitoring system shows the CAUTI infection rate is increasing nationally while the other shows a substantial and significant decrease. 

The authors suggest that using the CDC/NSHN system for its value-purchasing initiative should be examined carefully and properly validated. As the two systems give grossly discordant results, they believe that the difference results in the definitions and data collection methods. The CDC/NHSN system does not take into account catheter use, but focuses only on catheter care. Because the AHRQ system uses a denominator of hospital discharges, it measures both catheter use and catheter care. The authors note that a metric that does not account for catheter use may place hospitals that curtail their catheter use at a disadvantage. Hospitals may receive a financial penalty while they decrease catheter use, increase their workload on the nursing staff, and provide better patient care. The authors also question the reliability of self-reported data collected by hospital employees who may have a conflict of interest and are, for the most part, not independently validated. The CDC reports that only 20 of 50 states have validation checks for quality and completeness. 

The authors conclude that because the results of the two government sponsored CAUTI data collections differ, the CDC/NHSN method should be scrutinized so that hospitals are not unfairly penalize while they may actually be a well performing hospital. They note that any system with a financial penalty should be independently validated and they suggest that the CDC redefine the metric used for CAUTI by using a denominator that includes a risk-adjusted catheter use ratio. 

September 2015

Retrospective cohort study of inappropriate piperacillin-tazobactam use for lower respiratory tract and skin and soft tissue infections: Opportunities for antimicrobial stewardship. Havey TC, Hull MW, Romney MG, et al. American Journal of Infection Control, September 2015 (Volume 43, Issue 9, Pages 946–950). DOI:

Reviewed by Laura Buford, RN, BSN, CIC, Austin, TX

Antimicrobial stewardship has skyrocketed to the forefront of healthcare interest, including a national action plan set forth by President Obama. Overprescribing, inappropriate prescribing, and inappropriate usage by individuals have led to a serious problem with antibiotic resistance. However, antimicrobials are still needed and used daily in healthcare settings to treat known as well as suspected infections. This is done by using broad-spectrum antibiotics initially and then adjusting when organism is known.

Havey, et al, looked at the empiric use of piperacillin-tazobactam (TZP) in patients admitted with skin and skin structure infections (SSTIs) as well as lower respiratory tract infections (LRTIs) at two Vancouver hospitals within the same healthcare network (including same lab and electronic information system). They also reviewed duration of therapy with TZP from day three of admission. For this study, researchers retrospectively reviewed charts for 60 patients with SSTI and 169 patients with LRTI.

In the review of the SSTI cases, the empiric therapy with TZP was found to be inappropriate for 41.7 percent of the total cases. Of the inappropriate usage, the majority were cellulitis (with 86.7 percent inappropriate), with abscess close behind with 66.7 percent inappropriate use. A total of 138 patient days of inappropriate empirical use were seen with the SSTIs. A review done on day three could have potentially averted 89 days of inappropriate TZP therapy. The organisms seen in cultures on 42 of the patients were MSSA, streptococci, MRSA, and coagulase-negative staphylococci.

The LRTI review was mainly divided in to community-acquired pneumonia (CAP) or healthcare-associated pneumonia (HAP) (patients with recent admission, from nursing home or long-term acute care, receiving hemodialysis, chemotherapy, or wound care) with CAP being the larger group (101 patients vs. 68). It was found that empiric TZP therapy was deemed inappropriate for 61 percent of CAP patients and 4.3 percent of HAP patients. A total of 315 patient days of inappropriate empiric use were seen in the LRTIs. Had a day three review been done, potentially 167 days of inappropriate therapy could have been saved. 

The study reviewed records from January 1 through June 30, 2012. At the time, neither facility had an antimicrobial stewardship program. Havey, et al, concluded that a comprehensive and active antimicrobial stewardship program will positively affect prescribing practices. The study was limited by the retrospective design and having to solely rely on extraction from electronic records and perhaps not having all the information about antimicrobial choices at the time.

August 2015

Identifying the psychological determinants of handwashing: Results from two cross-sectional questionnaire studies in Haiti and Ethiopia. Contzen N, Mosler HJ. American Journal of Infection Control, August 2015 (Volume 43, Issue 8, Pages 826–832). DOI:

Reviewed by Timothy Bowers, MT(ASCP), MS, CIC, Vineland, NJ

The issues behind hand hygiene compliance have been at the forefront of infection prevention since Semelweis wrote the seminal article more than 100 years ago. Typically in healthcare we use education as a tool very often as the sole intervention to achieve a desired change in behavior. This effort goes to great lengths to illustrate the complexities of hygienic behavior. We could use this as a step to better understand our people and why they are exhibiting these behaviors.

The authors identify that many efforts are underway in the developing countries of Haiti and Ethiopia around hand hygiene. These efforts are undertaken by development and relief organizations in the form of awareness and knowledge building. Evidence shows the impact of those interventions is low in areas where the knowledge base is already high. Thus the continued effort around awareness may no longer be as effective. The authors, and the purpose of their article, is to find the next level of interventions after knowledge building. 

The authors used the psychological Risk, Attitudes, Norms, Abilities, and Self-Regulation (RANAS) of behavioral change theory in a face-to-face interview with the primary caregiver in each home. The RANAS behavioral change theory compiles many different theories so as to compare the impact of each individual theory on overall hand hygiene compliance. In terms of the study itself the number of households was high (811 in Haiti and 463 in Ethiopia) and skewed toward a major city. There was less than 5 percent refusal rate for each arm of the study. Mostly impoverished women who could not read or write participated in this study. 

The study showed varying impact of each factor (ability, norm, attitude, and self-regulation) related to self-reported hand hygiene behavior. Risk factors, meaning awareness and health knowledge, were sometimes unrelated to the intended behavior, yet comprised the majority of the effort to increase hand hygiene in these countries. The conclusion of the author is that if a standard framework for hand washing campaign is developed, it should focus on more than just risk (awareness and knowledge).

The limitations of this study noted by the authors are that technological and contextual factors were not included. Additionally, other limitations included to reduce the length of the survey some factors were only measured a few times, self-reported hand hygiene compliance is unreliable, and that the studies were conducted during emergency recovery time periods. 

July 2015

Variation in Healthcare Worker Removal of Personal Protective Equipment.Zellmer C, Van Hoof S, et. al. American Journal of Infection Control, June 2015 (Volume 43, Issue 7, Pages 750–751). DOI:

Reviewed by Maria Whitaker, MT, CIC, Cortland, NY

Appropriate removal of personal protective equipment (PPE) is crucial to reduce contamination to healthcare workers (HCWs), especially with all the new emerging pathogens. Breaches in use, including improper removal of PPE, may lead to transmission of infections.

The Centers for Disease Control and Prevention (CDC) recommendations for PPE removal were used in the study, which include removal of contaminated gloves followed by gentle removal of the gown from the back of the neck in the patient’s isolation room. This is considered full compliance. “Gentle” removal of PPE is careful, not forceful, movements.

Direct observations were performed by trained, non-infection prevention staff.  They were given a checklist to collect the data. Observations were completed and documented on all HCWs entering and exiting patient’s rooms during an 18-day period, covering five different units in the tertiary academic medical center. 

Deviations from protocol were common. The majority of staff did not remove their PPE in the correct order, and most of these staff did not properly dispose their contaminated PPE in the patient room. Many HCWs did not tie the backs of the gowns, which lead to the gown falling over the patient. Also, upon removal, the staff touched the contaminated gowns and gloves to their uncontaminated work clothes or with their bare hands. (Exact rates of compliance can be found in the article.)

Limitations in the study include the following: observations were not seen if doors were closed, the study was done at a single site, and contamination of the HCW following removal of PPE was not assessed.

This study indicated that more education and collaboration with hospital and HCW leaders to improve compliance is needed. 

June 2015

Automated tracking and ordering of precautions for MDR organisms. Quan K, Cousins SM, et. al. American Journal of Infection Control, June 2015 (Volume 43, Issue 6, Pages 577–580). DOI: 

Reviewed by Barbara A. Smith, RN, BSN, MPA, CIC, New York, NY 

The June issue of AJIC contains several articles on the use of technology to assist with infection prevention activities. In one of these articles, Quan et. al. discuss their success in developing an automated system to identify patients requiring contact precautions via the electronic health record and having a seamless means to begin contact precautions that is not dependent on the infection preventionist (IP).

Their program was designed to identify patients who had positive cultures for C. difficile, MRSA, VRE, and MDR gram-negative bacteria, including CRE. Both infected and colonized patients were included. The program applied to currently hospitalized patients, as well as the past history of the patient. The time frame for the retrospective review varied by the organism and an algorithm was created to determine how far in the past the system should search. For example, cases of C. difficile were identified if they occurred within the past 60 days, whereas CRE patients were flagged indefinitely.

When a case was noted, the system sent a flag to the EHR that could be seen by the care providers immediately. Additionally, contact precautions were ordered. There was the ability for the practitioner to review and dispute the order if certain clinical symptoms were not present (e.g., a past history of C. diff but no diarrhea at this admission).

They created an organism specific algorithm to decide when contact precautions could be discontinued. 

The authors noted the program had the following benefits:

  • Allowed real time monitoring of events. They realized the IP might have other priorities that take them away from locating patients needing isolation.
  • Isolation was implemented in a more timely fashion thereby reducing the possibility of inadvertent transmission of organisms or contamination of the environment.
  • Permitted appropriate discontinuation of precautions when no longer necessary. This may be a cost saver and certainly improves patient satisfaction.
  • An unexpected benefit to the EHR flags was the use by the physicians to guide therapy.

Their project marries the goals of the Joint Commission, SHEA, IDSA, and HICPAC that requires health systems to have a means to identify patients with MDROs including upon readmission. Although their efforts likely required a significant commitment from the facility, it saved 850 hours of the IP’s time, which equates to 43 hours per 1000 admissions. This is approximately one half of a work year.   

May 2015

Cleaning and disinfecting environmental surfaces in healthcare: Toward an integrated framework for infection and occupational illness prevention.Quinn MM, Henneberger PK, et al. American Journal of Infection Control, May 2015 (Volume 43, Issue 5, Pages 424-434). DOI: 

Reviewed by Vicki Allen, MSN, RN, CIC, Beaufort, SC

The cleaning and disinfection of environmental surfaces within healthcare organizations has become a focus not only for healthcare organizations themselves, but also from the solicited and unsolicited scrutiny of patients, the general public, and the media. Healthcare organizations are viewing the results of this scrutiny in several ways, including patient satisfaction surveys (e.g., Hospitals Consumer Assessment of Healthcare Providers and Systems, LeapFrog Group) such that patient perception of hospital cleanliness can impact overall patient satisfaction. The Centers for Medicare & Medicaid Services (CMS) are imposing penalties for healthcare-associated infections (HAIs) and focusing efforts on HAI prevention. Part of this effort includes the cleaning and disinfection of the environment, as well as instruments and equipment used on patients. Transparency and publishing of hospital data allows the public to shop around and offers the option to pick and choose the best and highest scoring hospitals to entrust for their care.  

This study presents the results of the findings from an international cleaning and disinfecting working group of more than 40 members that reviewed current knowledge and policy, gaps in knowledge, and needs for future research and practice. The study presents very helpful information and considerations for the infection preventionist (IP) to help reduce the incidence of infectious disease and colonization in healthcare workers and patients. It offers guidance to the IP for product selection, provides recommendations for hazard communication and training, and presents the provision of safer alternatives to the many users of these products throughout the healthcare environment.  

The focus to keep the healthcare environment and equipment clean, safe, and disinfected is a primary infection prevention strategy, proven many times over in the literature. The study notes that this, along with the emphasis to decrease the incidence and risk for HAIs and conditions, can result in exposure to many cleaning and disinfectant products. A thorough investigation of all disinfectants and cleaners used within the organization should review more than just the “kill claim” of the product. The authors note that considerations must be reviewed and acknowledged in an effort to protect the patient and the user from potential acute and chronic health effects, such as respiratory illness that could result from exposure.   

The study recommends utilizing a multidisciplinary team—including occupational health—and an integrated approach to selection and use, hazard communication, consideration of safer alternatives, and appropriate education and training, as this is essential in the prevention of occupational illness promotion of patient safety.   

March 2015

Predictors of asymptomatic Clostridium difficile colonization on hospital admission. Kong LY, Dendukuri N, et. al. American Journal of Infection Control, March 2015 (Volume 43, Issue 3, Pages 248–253). DOI: 

Reviewed by Cynthia A. Kohan, MS, CIC, Waterbury, CT 

In the article, Kong and colleagues attempt to quantify the occurrence of Clostridium difficile (C. diff) colonization in patients admitted to six acute care hospitals in Quebec, Canada. This is an extension of a study conducted in 2006 to determine the host and pathogen risk factors for healthcare-associated C. diff infection (CDI). In this study, an attempt is made to determine host and pathogen characteristics associated with asymptomatic colonization with C. diff at the time of hospital admission. 

Stool samples or rectal swabs were analyzed in 5,232 patients from six acute care, university-affiliated hospitals between March 6, 2006 and June 25, 2007. Samples were taken upon admission, once per week and upon onset of diarrhea. A culture for toxigenic C. diff was performed on each sample. Cytotoxin assay and nucleic acid amplification testing was performed on the isolates to identify specific toxins, and pulse-field gel electrophoresis was performed for strain typing. 

Demographic data and information on known risk factors were collected on all participating patients. This information included the use of antibiotics, chemotherapy, proton pump inhibitors, H2 blockers, corticosteroids and non-steroidal anti-inflammatory drugs in the eight weeks prior to the hospital admission. Additional factors included whether the patient was being hemodialyzed, receiving home care, or used a nasogastric tube in the eight weeks preceding hospitalization. 

Those patients culture positive for C. diff on admission, or within the first 72 hours of their stay, but had no symptoms of diarrheal disease, were considered to be an asymptomatic carrier. Risk factors for this group were compared to those testing negative for C. diff

Of the 5,232 patients tested, 4.05 percent were determined to be asymptomatic carriers. Multivariate logistic regression analysis showed that hospitalization within the last 12 months, use of corticosteroids, prior CDI, and the presence of antibody against toxin B were associated with colonization on admission. The authors conclude that additional study is needed because it is still unclear if the asymptomatic carrier may be contributing to the transmission of C. diff. History of CDI within the six months prior to admission may signify that the patient remains colonized, and able to shed, for a significant period of time. Tests of cure are not recommended and common practice is to discontinue isolation precautions upon resolution of symptoms. Screening a population of patients with targeted risk factors may prompt early isolation, a decreased amount of environmental contamination and decreased transmission.

December 2014

Middle East Respiratory Syndrome Coronavirus: Implications for Health Care Facilities. Maltezou HC, Tsiodras S. American Journal of Infection Control, December 2014 (Volume 42, Issue 12, Pages 1261–1265). DOI:

Reviewed by Cynthia A. Kohan, MS, CIC, Waterbury, CT 

Middle East Respiratory Syndrome coronavirus (MERS-CoV) was first identified in a 60-year-old patient with fatal pneumonia in September 2012. Later, it was discovered that a cluster of severe respiratory infections that occurred in March 2012 was related to the same virus. In the following two years, 191 laboratory confirmed cases were identified, of which 82 were fatal.  In March 2014, an increase in cases was noted with many occurring in healthcare settings. By May 2014, the number of identified cases rose to 536 with 145 fatal cases.  The authors of this article reviewed published case descriptions and data about MERS-CoV and presented information on transmission and prevention of this disease with special emphasis on the prevention of healthcare-associated cases. 

Molecular analysis of MERS-CoV and similar viruses from camels and bats suggest that these two species are the natural reservoir for the virus. Notably, the virus is stable in camel milk and suggests that zoonotic transmission occurs from the ingestion of the raw milk. The authors suggest that because there is no evidence of a genetic change in the virus to increase its transmissibility, an increase in human to human transmission from March to May 2014 may be due to an increase in primary infections as well as an increase in hospital-acquired cases.  

Symptoms noted in infected patients range from none or mild symptoms, to severe pneumonia, acute respiratory distress syndrome, septic shock, and multi-organ failure. Other less severe symptoms include fever and cough, chills, sore throat, myalgias, arthralgia, vomiting, and diarrhea. It is noted that patients with existing co-morbidities will more likely develop severe symptoms. 

A two-month long outbreak in Saudi Arabia, in four affiliated healthcare facilities and involving 34 patients including two healthcare workers was described. This is the largest outbreak studied thus far. Spread to healthcare workers is speculated to occur due to inadequate infection control practices with delayed identification of cases. This outbreak also raises the possibility that transmission can occur not only from direct human-to-human contact, but also indirect contact with contaminated environmental surfaces or fomites.  It was found that the virus can remain viable for up to 48 hours on surfaces under common hospital environmental conditions.  It was also determined through study of this outbreak that the incubation period is approximately 5.2 days.

Although this viral syndrome is primarily affecting the Arabian Peninsula, easy access to travel requires that hospitals throughout the globe be prepared to identify and isolate this virus. As there is no treatment or vaccine against MERS-CoV, prompt isolation is key to prevent additional transmission. In the U.S., the Centers for Disease Control and Prevention recommends that patients with confirmed or suspected MERS-CoV should be placed on contact and airborne precautions. This requires the use of an N95 respirator mask or equivalent, gloves, isolation gown, and eye protection. A negative pressure airborne isolation room is also required.  

Much more knowledge and research is needed regarding this viral infection. The authors suggest several areas for additional study. These include a clearer determination of transmission pathways, the role asymptomatic cases play in transmission, as well as the development of a vaccine and specific antiviral agents. 

September 2014

Effect of a Ventilator-Focused Intervention on the Rate of Acinetobacter baumannii Infection among Ventilated Patients. Cohen R, Shimoni Z, Ghara R, et al. American Journal of Infection Control, September 2014 (Volume 42, Issue 9, Pages 996–1001). DOI: 

Reviewed by Laura Buford, RN, BSN, CIC, Austin, TX

Since 2010, Laniado Medical Center (LMC) in central Israel had noted an increase in multidrug-resistant Acinetobacter baumannii in its ventilated patients. LMC was seeing prolonged hospitalization and ventilation as well as increased mortality. Investigations of outbreaks seem to indicate that the ventilators themselves were colonized; thus, focusing on this factor could be critical to controlling the outbreaks in patients.

The LMC team reviewed the current guidelines for handling and maintaining respiratory equipment and found them to be lacking in evidence and not addressing key circuit components. In addition to the guideline review, local practices regarding care of ventilator circuits were also reviewed. Because critical areas were not addressed properly, the LMC group implemented a local policy and conducted a study from those interventions. The study was conducted January 1, 2012 through March 31, 2013 with the interventions implemented April 2012 through June 2012.

The new policy included the following: 1.) breathing circuits and external bacterial filters changed every 7-14 days; 2.) stopping use of external filter in inspiratory port; 3.) all internal filters were replaced and subsequently had routine autoclave sterilization done every 4-8 weeks; 4.) daily replacement of heat and moisture exchanger filters; and 5.) keeping metered dose inhalers (MDI) connected to tubing unless no longer needed or soiled. The LMC researchers monitored these interventions for a three month period but maintained the interventions thereafter. After certain exclusions, 321 patients took part in the study and 702 sputum cultures were reviewed. A. baumannii was reduced from 33 percent to 16 percent, which was statistically significant. The time to infection was also longer after intervention (from 21 to 59 days).

A limitation of the study, as pointed out by the LMC researchers, is that more than one intervention was done at the same time. This makes it hard to know which of the five interventions was the key factor in reducing these infections. Another limitation involves the range for the circuit and filter change (7-14 days) and for the sterilization (4-8 weeks), because there is no indication of how the team decided which spectrum of the range to use.  

July 2014

Impact of daily chlorhexidine baths and hand hygiene compliance. Martínez-Reséndez MF, Garza-González E, Mendoza-Olazaran S, et al. American Journal of Infection Control, July 2014 (Vol. 42, No. 7, Pages 698-701). DOI:

Reviewed by Crystal Heishman, BSN, RN, CIC, ONC, Louisville, KY

Previously recognized as nosocomial infections, healthcare-associated infections (HAI) are well-known causes of morbidity and mortality. Citing that 25 percent of HAIs develop in critically ill patients, a team in Nuevo Leon, Mexico took on the challenge of studying the combined effects of chlorhexidine bathing and hand hygiene on infection rates. 

The study, performed at a 450-bed tertiary care hospital, took place over an 18-month period.  This timeframe was divided into six month study periods: pre-intervention period (PIP), intervention period (IVP), and post-intervention period (PoIP).  During the PIP, patients were bathed with soap and water, as per normal routine. During the IVP, patients were bathed daily with 2% impregnated chlorhexidine wipes, hair washed with 0.12% chlorhexidine foaming shampoo, and a hand hygiene maintenance program was initiated. Finally, the PoIP carried on with the hand hygiene program, but bathing was returned to soap and water. Prior to the IVP, staff members were instructed on a uniform method for bathing. Hand hygiene practices were discussed in small group settings with verbal reminders and frequent feedback. Observations were performed by a select group of people during the study. 

Notably, infection rates decreased significantly between the PIP phase and the IVP.  The global infection rate, initially 64.44 per 1,000 hospital days, dropped to 43.30 during the IVP. These rates rose again during the PoIP phase to 58.45 per 1,000 patient days. Similar results were seen for ventilator-associated pneumonia (VAP) and for catheter-associated urinary tract infections (CAUTI).  Although a decrease was seen for central line-associated bloodstream infections (CLABSI), the decrease was not significant. 

During the process, it was noted that while Gram-positive bacteria decreased, there was still a persistence of most Gram-negative bacteria. Unexpectedly, a decrease in cases related to Acinetobacter baumannii was discovered, dropping from 21 cases during the PIP to just seven during the IVP. In reviewing infection type, it was revealed that VAP cases relating to A. baumannii and CAUTI related to Candida spp were significantly reduced during the PIP to IVP timeframe.

Hand hygiene compliance during this study increased from 59.48 percent during the PIP to 71.23 percent during the IVP. This rate rose to 74.24 percent during the PoIP. This indicates that awareness was sufficient to significantly raise and maintain compliance. Chlorhexidine bathing was 97 percent compliant as well.  

In conclusion, chlorhexidine bathing combined with increased hand hygiene compliance had an overall effect on global infection rates in the intensive care units studied. While Gram-negative bacteria remained persistent, a substantial reduction in A. baumannii and general Gram-positive bacteria did occur. VAP and CAUTI experienced significant reduction; however, the decrease in CLABSI was not found to be significant. Incidence of A. baumannii in VAP and Candida spp in CAUTI experienced a noteworthy reduction as well. Hand hygiene compliance alone did not further decrease infection rates, thus signaling the importance of a combined approach.  

June 2014

Hospital Clostridium difficile outbreak linked to laundry machine malfunctionSooklal S, Khan A, Kannangara S. American Journal of Infection Control, June 2014 (Vol. 42, Issue 6, Pages 674-675). DOI:

Reviewed by Maria Whitaker CIC, Cortland, NY

Clostridium difficile is a spore-forming anaerobic bacillus that is associated with diarrheal disease. C. difficile bacteria and spores are shed in the feces of some people. The spores of C. difficile can survive on surfaces for prolonged periods of time. These spores contaminate the environment.  They are spread via healthcare workers hands and suboptimal environmental cleaning practices.

An academic hospital in Pennsylvania noted a drastic increase in the number of cases of healthcare facility-onset C. difficile between April 2013 and June 2013. A multidisciplinary team was formed to investigate. They looked at hospital admissions, community-onset prevalence, affected hospital floors, staffing, laboratory testing, and room cleaning practices and found that nothing had really changed to alter the surveillance data.

A breakthrough came when the laundry records were examined. Approximately 100 loads of mop heads were washed without bleach. The machine had accidently been switched to microfiber setting where the preload bleach was not added. The poorly cleansed mop pads were then reused, spreading the C. difficile spores.

To fix the problem, the microfiber setting was made obsolete. All mop pads and rags were double washed, and all hospital rooms were thoroughly cleaned. Education was provided, stressing hand hygiene, use of PPE, and appropriate isolation precautions, as well as adherence to cleaning protocols.

During the two months following the intervention, no cases of healthcare facility-onset C. difficile were noted. 

This case investigation shows the importance of surveillance and outbreak investigations to reduce the risk for future occurrences. 

May 2014

Surgical wound irrigation: A call for evidence-based standardization of practice. Barnes S, Spencer M, Graham D, et al. American Journal of Infection Control, May 2014 (Vol. 42, Issue 5, Pages 525-529). DOI:

Reviewed by Barbara A. Smith, RN, BSN, MPA, CIC, New York, NY 

Although long used in surgery, there is little evidence or recommendations from the American College of Surgeons, the Association of PeriOperative Registered Nurses, or APIC to support wound irrigation. An expert panel consisting of surgeons, IPs, and epidemiologists reviewed current practices and studies related to wound irrigation and identified three variables: delivery method, the volume of solution, and additives to the solution.

The amount of pressure appears to be the significant factor of the delivery mode. Studies indicate high pressure is more effective than low pressure in removing bacteria and foreign material from the wound. The authors note three disadvantages of high pressure:  it may lead to tissue damage, it can push bacteria deeper into tissues, and it can increase the risk of body fluid exposure to the team.

Data related to pulsatile delivery of irrigants remains inconclusive, and a JAMA article is cited that describes an outbreak of Acinetobacter baumannii because of its use. The volume of fluid to use also remains unresolved.

The type of solution such as sterile water or saline and additives (antibiotics, antiseptics and surfactants) are discussed. 

Data is presented against the use of antibiotic solutions citing cardiac and orthopedic studies that showed no difference in outcomes. Antibiotic solutions may contribute to toxicity and the development of resistance.

Surfactants have demonstrated effectiveness in animal models and cadaveric tissue in reducing bacterial contamination. However, negative effects such as hemolysis and impaired clotting limit their usefulness. 

None of the commonly used antiseptics (e.g., povidone-iodine, hydrogen peroxide) have demonstrated efficacy in reducing contamination without toxicity. With one exception (a device containing chlorhexidine and sterile water), none have FDA approval for surgical wound irrigation. 

The authors also mention the use of wound irrigation as a means to reduce the airborne contamination of the surgical site.

The authors summarize the following practices about surgical irrigation that are supported by published evidence:

  • Elimination of antibiotic solution 
  • Avoidance of surfactants 
  • Use of sterile normal saline, sterile water and one specific medical device containing CHG followed by sterile saline

April 2014

Major biological characteristics of Acinetobacter baumannii isolates from hospital environmental and patients’ respiratory tract sources. Obeidat N, Jawdat F, Al-Bakri A, et al. American Journal of Infection Control, April 2014 (Volume 42, Issue 4, Pages 401–404). DOI:

Reviewed by Laura Buford, RN, BSN, CIC, Austin, TX

Jordan University Hospital (JUH), a 550-bed tertiary care teaching hospital, conducted a prospective study to compare the survival potential, biofilm production, and antimicrobial resistance in Acinetobacter baumannii isolates from both hospital (ICU) environmental cultures and respiratory tract cultures of ICU patients. Previous studies have shown A. baumannii’s ability to survive for prolonged periods of time in unfavorable conditions, hence its rising prominence as an important infectious agent.

The nine month study (May 2009 – February 2010) looked at a total of 149 environmental cultures and 142 respiratory cultures collected in the 3 adult ICUs. Various items in the environment, such as pillows, sinks, floors, bed linens, and patient ventilation masks, were sampled randomly with 74 A. baumannii isolates recovered. The respiratory cultures were gathered using bronchoalveolar lavage, endotracheal aspirate, and sputum and were collected from 93 patients within the first 48 hours after ICU admission. Sixty-four isolates grew A. baumannii.

Other than Colistin and Tigecycline, both the environmental and respiratory cultures showed more than 60% resistance to antimicrobial agents (Amikacin, Aztreonem, Ceftazidime, Ciprofloxacin, Gentamycin, Imipenem, Meropenem, and Zosyn were the other agents). Temperature, pH, and water were studied for effect on A. baumannii growth. Isolates from either source did not grow at 4°C or 48°C but grew well at 37°C, 42°C, 45°C, and laboratory room temperature (18-24°C). Environmental isolates survived for 23 days in distilled, tap, and 0.9% saline water with a pH range of 4.5-8. The respiratory isolates liked a higher pH (5.5-8) and preferred tap and 0.9% saline water.

The last area the study addressed was biofilm production. Both the environmental and respiratory specimens formed biofilm with no significant difference in ability. Well-plates and catheters were used for both sets of isolates. A 60-second application of Sterillium or 0.2% sodium hypochlorite (NaClO) removed 99.99% of the biofilm. In dirty conditions, a 0.3% solution hypochlorite was required to have the same biofilm reduction.

The study concluded that A. baumannii strains isolated from hospital environment and the respiratory tract of hospitalized patients have mostly similar antimicrobial resistance patterns and biological characteristics, which allow them to survive very well in the hospital environment. It is extremely important to employ proper disinfection and sanitation measures in order to control the spread of Acinetobacter baumannii.

March 2014

Duration of colonization with Methicillin-resistant Staphylococcus aureus (MRSA) in an acute care facility: A study to assess epidemiologic features. Rogers C, Sharma A, Rimland D, et al. American Journal of Infection Control, March 2014 (Volume 42, Issue 3, Pages 249-253). DOI:

Reviewed by APIC’s Communications Committee

Healthcare facilities often presume that patients with a history of Methicillin-resistant Staphylococcus aureus (MRSA) continue to be colonized for an extended period of time. Patients with a history of MRSA infection and/or colonization are typically placed under isolation precautions upon readmission to healthcare facilities despite a lack of evidence for duration of colonization. Due to this lack of knowledge, it is unclear how long these patients pose an infection control risk. Previous studies have not been comparable and produced varying colonization estimates ranging from a median of 5 months to longer than 48 months. Identifying factors associated with prolonged MRSA colonization could help target efficient patient screening techniques.

An MRSA directive, focusing on limiting MRSA transmission within Veterans Affairs (VA) hospitals, was issued in January 2007. A cohort study of patients hospitalized between October 1, 2007 and July 31, 2009 was conducted by the Atlanta VA Medical Center to determine the duration of and risk factors associated with MRSA colonization among discharged patients. Three mutually exclusive comparison cohorts were identified:

  1. Cohort A – Patients who had both a MRSA infection and nasal colonization at discharge.
  2. Cohort B – Patients who had a MRSA infection but no nasal colonization at discharge.
  3. Cohort C – Patients who did not have a MRSA infection but had nasal colonization at discharge.

The study included 231 patients with documented MRSA infection and/or nasal colonization who also provided nasal swabs for culture after discharge. Colonization was documented in 39.9 percent of these patients. The overall, median duration of colonization was 33.3 months (range of 18 to 44 months). Cohort A had a significantly longer duration of colonization compared to the other cohorts. In addition, the total duration of hospital stay from previous admissions was a predictor of persistent MRSA colonization, independent of the number of admissions.

Overall, this study determined MRSA colonization is typical for the first six months post discharge. Patients with MRSA infections and colonization (Cohort A) maintain a longer duration of colonization, suggesting a higher primary inoculum of bacteria may be an important element for persistent colonization. While further research needs to be completed, these findings suggest flagging of patients who have both MRSA infection and colonization may be required for longer time periods. 

February 2014

Accuracy of a radiofrequency identification (RFID) badge system to monitor hand hygiene behavior during routine clinical activities. Pineles LL, Morgan DJ, Limper HM, et al. American Journal of Infection Control, February 2014 (Volume 42, Issue 2, Pages 144-147) DOI:

Reviewed by Carol McLay, DrPH, RN, CIC

Hand hygiene is a critical part of infection prevention and health organizations are continuously struggling to improve health care personnel (HCP) compliance with hand hygiene (HH) activities. The current gold standard for monitoring compliance is direct observation, which is time-consuming and costly.

To improve compliance, a growing number of healthcare facilities are installing automated hand hygiene systems. Automated systems include counting systems, ultrasound, infrared, Wi-Fi, and radiofrequency identification (RFID). However, there is little evidence-based research documenting the reliability of these devices in clinical settings. 

The aim of this multicenter study was to assess the accuracy of the RFID badge in detecting HCP activity including room entry, room exit, and HH compliance. The authors compared direct observation with data collected by the RFID system in a simulated validation or idealized setting (Phase 1) and to a real-life clinical setting at two large academic medical centers (Phase 2).

Accuracy for identifying HH events was high in the validation setting (88.5 percent) but was relatively low (52.4 percent) during real-life clinical activities. This difference was statistically significant (P<0.01). Accuracy for detecting HCP movement into and out of patient rooms was also high in the simulated setting but not in the real-life clinical setting (100 percent accuracy on entry and exit vs. 54.3 percent accuracy on entry and 49.5 percent on exit, P<0.01).  The authors attribute this result to improper positioning of HCP in front of the sensors, and quick “fly-by” handwashing.

The study is limited by the small study population of 31 HCP providing data in the clinical setting. Furthermore, overall unit level HH compliance was not monitored before and after installing the RFID system.  However, this is the first multisite validation of a commercially available RFID HH monitoring system, and the study provides useful information to help infection preventionists understand the limitations of using technology as a monitoring tool.

The authors conclude that more research is necessary to further develop these systems and improve accuracy prior to widespread adoption.

January 2014

Association between health care workers’ knowledge of influenza vaccine and vaccine uptakeJaiyeoba O, Villers M, Soper DE, et al. American Journal of Infection Control, January 2014 (Volume 42, Issue 1, Pages 69-70). DOI:

Reviewed by Laura Buford, RN, BSN, CIC, Austin, TX

Influenza vaccination rates among healthcare personnel (HCP) have, historically, been low.  Medical University of South Carolina (MUSC) saw its vaccination rates prior to 2010 ranging from 40-60 percent, with vaccination being voluntary.  For the 2010-2011 season and beyond, MUSC instituted a new policy requiring all employees who refused influenza vaccine to complete a declination form indicating medical contraindication, religious belief, or personal preference.  Those refusing would also have to wear a mask at all times when in patient care areas during the designated flu season.

A cross-sectional survey study was conducted to evaluate HCP knowledge and opinions regarding influenza vaccine.  The study included nursing staff, attending and resident physicians, and medical students.  Only 21 percent of the surveys were completed. Vaccine knowledge survey results noted a) 88 percent  of physicians and 67 percent of nurses agreed it was unlikely for the vaccine to cause severe reactions; b) 69 percent of  physicians and 42 percent of nurses agreed vaccine was effective in preventing influenza; and c) 84 percent of physicians and 70 percent of nurses agreed it was unlikely to contract influenza from the vaccine.

In 2009 with the voluntary vaccination program, the facility had 55 percent compliance rate.  For the 2010-2011 season, the overall vaccination rate had a significant increase to 95 percent (P <.0001).  They concluded that the vaccine uptake was due to the declination form and the requirement to wear a mask during influenza season.  The study revealed that staff who had been previously vaccinated were more likely to receive subsequent vaccinations.  Reasons for declining vaccine were “personal preference” (43 percent of HCP), “concerned about adverse effects” (18 percent), “influenza-like illness with previous vaccination” (16 percent), and only 4 percent had medical contraindications.  

The study results may suggest a shift in culture emphasizing patient safety and prevention of adverse events, especially in physicians as 44 percent of them received the vaccine because of patient care compared to only 23 percent of nurses.  More education for HCP is needed about the benefits of vaccination, the transmission of disease, and the HCP role in educating patients as they may get a “mandated” vaccine but not recommend or offer the vaccine.  MUSC’s study findings mirror that of other organizations that have concluded that voluntary programs are less effective in part because of HCP misconceptions about the vaccine.

December 2013

Successful reduction in catheter-associated urinary tract infections: Focus on nurse-directed catheter removal. Parry MF, Grant B, Sestovic M. American Journal of Infection Control, December 2013 (Volume 41, Issue 12, Pages 1178-1181). DOI:

Reviewed by Maria Whitaker BS, MT, CIC Cortland, NY

Catheter-associated urinary tract infections (CAUTIs) are the most common hospital acquired infection. They lead to excess costs, increased length of stay, and patient morbidity.

Stamford Hospital, a 300-bed community teaching hospital in Connecticut, achieved a 50 percent hospital-wide reduction in catheter use and a 70 percent reduction in CAUTIs over a 36-month period. The primary component of this initiative was a nurse-directed, catheter removal protocol. On a daily basis, nurses used a pre-approved checklist to determine if the catheter was still needed. If criteria were not met, the physician was notified and the nurse removed the catheter.

The interventional study utilized three other key elements:

  1. Physician documentation of the criteria for catheter insertion was mapped to the nursing checklist. A physician order for catheter use was linked to the order for “Foley Maintenance Protocol” for nursing which included standard care and the nurse-driven removal protocol.
  2. A device-specific charting module was added to physician electronic progress notes to remind them that the patient has a catheter and questioned if it was still indicated.
  3. Bi-weekly unit-specific feedback on catheter use rates and CaUTI rates was presented to key stakeholders.

This study showed that lower catheter use, and reduced CAUTI rates were effectively reduced by the implementation of the nurse-driven removal protocol. Savings from the initial program were estimated at $100,000 and six lives. 

November 2013

Tensions inherent in the evolving role of the infection preventionist. Conway LJ, Raveis VH, Pogorzelska-Maziarz M, et al. American Journal of Infection Control, November 2013 (Volume 41, Issue 11, Pages 959-964). DOI:

Reviewed by Elizabeth Monsees, RN, MSN, MBA, CIC, Kansas City, MO 

Infection Prevention and Control is a well-established science with an evolving role for the infection preventionist (IP). Using documentation from the Certification Board in Infection Control (CBIC), Conway, et al., identify that in a period of five years the IP paradigm shifted from primary collectors of data to policy setters and leaders of performance improvement teams. The authors outline that while staffing has increased since 1976, it has not accounted for the exponential growth of responsibilities beyond surveillance, despite that task persisting as the largest segment of IP utilization. 

The authors conducted a qualitative study with IPs purposively sampled from 250 nonspeciality acute care hospitals across the United States. The interviews addressed the overall structure, function, roles, staffing composition, regulatory requirements and barriers to infection prevention. Respondents all worked in settings with greater than one IP, average tenure was 8.5 years and experience ranged from 1-26 years, and 52 percent were certified in infection prevention and control. Four themes were reported: “1) expanding responsibilities outstrip resources 2) shifting role boundaries create uncertainty 3) evolving mechanisms of influence involve trade-offs and 4) the stress of constant change is compounded by chronic recurring challenges.”  

IPs articulated a responsibility to lead organizational efforts but lacked authority to hold staff accountable. Additionally, dialog with IPs yielded that competing administrative or technology demands limited the amount of time they could interact with staff “that leads to real change.” This perception, as noted by the authors, has questionable association with institutional compliance with recommended infection prevention strategies. One of the central tenets of APIC’s Strategic Plan 2020 which supports implementation science methodologies, is to help inform IPs of leadership or educational approaches with proven effectiveness. An understanding of systems-thinking and implementation research will help the IP influence behaviors and move beyond awareness (education) through application (practice) to the way the individual performs consistently (sustainability). 

October 2013

Vancomycin-resistant Enterococcus outbreak in a neonatal intensive care unit: Epidemiology, molecular analysis and risk factors. Iosifidis E, Evdoridou I, Agakidou E, et al. American Journal of Infection Control. October 2013 (Volume 41, Issue 10, Pages 857-861). DOI:

Reviewed by Irena L. Kenneley, PhD, APRN-BC, CIC, Cleveland, OH

Vancomycin-resistant Enterococcus (VRE) has been associated with outbreaks occurring in Neonatal Intensive Care Units (NICU).  As a group, the Enterococci are known to cause serious healthcare-associated infections (HAIs), such as bacteremia, peritonitis, endocarditis, and device-related infections. These infections have occurred not only in adults, but in children and neonates as well. In recent years, there has been a documented increase in VRE infections in children and neonates.

Infections caused by VRE have higher mortality rates, longer lengths of hospital stay, and higher costs than the vancomycin susceptible strains. When an outbreak has occurred and VRE was the causative agent, there usually were high levels of colonization by VRE preceding the outbreak. Therefore it is important to detect VRE colonization so that implementation of infection prevention strategies can be instituted. 

This study began after the occurrence of two serious cases of VRE infections (ventriculoperitoneal shunt and a bacteremia both successfully treated with linezolid) in a 44-bed NICU in Greece. Bundled infection control interventions included: 1) active surveillance cultures for VRE; 2) enhanced infection control measures; and 3) audits on antimicrobial use. Infection preventionists worked with NICU nurses and physicians as a team to enhance infection control practices, such as contact precautions for all colonized neonates and standard precautions for non-colonized neonates. Those neonates colonized with VRE were cohorted. Written daily reports on the neonates’ VRE status were distributed to all clinicians. Finally, extensive environmental surface cleaning was maintained throughout the outbreak.

The timeframe for the study was June 2008 to December 2008. The VRE isolates were identified using polymerase chain reaction and pulse-field gel electrophoresis techniques. A case-control study approach was conducted in order to identify predictors for neonates at higher risk.

Results of active surveillance cultures showed that 39.9 percent of neonates in the NICU were colonized with VRE. The institution of an active surveillance program in the NICU was found to be extremely important in preventing the further spread of VRE infection. The case-control study results indicated that there was a significant association between a high prevalence of VRE colonization in the NICU and antimicrobial use actually promoted the acquisition of VRE. The authors described colonization pressure occurs when there is a high prevalence of VRE in the NICU.

Conclusions of the study indicate that in order to stop the spread of VRE in the NICU, enhanced infection control measures and optimizing the use of vancomycin led to a significant reduction of VRE incidence and prevalence in the NICU. The authors state that continuous monitoring of bundled infection control interventions in daily practice and the implementation of an antimicrobial stewardship program are essential for optimal infection prevention of VRE.

September 2013

Prevalence and factors associated with 2009 to 2011 influenza vaccinations at a university medical center. Crowley KA, Myers R, Magda LA, et al. American Journal of Infection Control. September 2013 (Volume 41, Issue 9, Pages 824-830). DOI:

Reviewed by Vicki Allen, MSN, RN, CIC, Huntsville, NC

Mandatory Influenza vaccination of healthcare personnel has become a requirement of many healthcare organizations nationwide. Hospitals and healthcare systems are making the decision to implement mandatory flu vaccination policies in an effort to protect healthcare personnel, patients, families, and visitors against influenza illness. As the vaccination of healthcare personnel can result in reduction of influenza infection and absenteeism, not to mention patient safety factors, it is not difficult to see why healthcare organizations including ACIP, SHEA, APIC, and IDSA are strongly promoting this effort.  

This study was designed to identify factors that influenced influenza vaccination during two flu seasons at a major university medical center. A questionnaire requiring around 10 minutes to complete included questions on demographics, general knowledge, vaccination history and barriers to taking the vaccine. It was distributed to clinical and non-clinical personnel.

Review of the results indicated that vaccination rates were highest for clinical personnel over non-clinical personnel. The point was driven home by highlighting that all personnel are essential including non-clinical and support staff, so it is imperative that the importance of the vaccine is stressed for all personnel working in the organization. The study further identified that non-clinical personnel were more apt to take the flu vaccine if they had received prior training again underscoring the significance of education, training, and promotion of the annual flu vaccine.  

As TJC (The Joint Commission) requires accredited organizations to annually evaluate influenza vaccination rates and the reasons given for declining the flu vaccine, this article is able to provide some additional knowledge and helpful discussion regarding effective planning and development of influenza campaigns. This study draws attention to the usefulness of reviewing declination reasons in an effort to create and implement strategies aimed at increasing compliance of healthcare workers taking this vaccine.  

June/July 2013

Decreasing methicillin-resistant Staphylococcus aureus surgical site infections with chlorhexidine and mupirocin. Thompson P, Houston S. American Journal of Infection Control. July 2013 (Volume 41 issue 7 Pages 629-633). DOI:

Reviewed by Carol McLay, RN, MPH, DrPH, CIC, Lexington, KY

Methicillin-resistant Staphylococcus aureus (MRSA) has become the leading causative pathogen for surgical site infections (SSIs) in community hospitals. Infections with MRSA are associated with increased mortality rates, longer lengths of hospital stays and increased hospital expenditures.

Prevention of MRSA colonization and infection has been a major focus of the infection prevention team at in this university-affiliated, private not-for-profit, level 1 trauma center in Florida, with a primary goal of preventing hospital-acquired infections in high-risk patient populations.

This case control study examined MRSA SSI rates before and after implementation of a facility-wide MRSA SSI protocol. All adult patients undergoing cardiac, orthopedic, vascular, or neurosurgical procedures  received a prophylactic five-day course of intranasal mupirocin and daily nonrinse two percent chlorhexidine gluconate (CHG) cloth baths beginning one day before surgery and continuing the day of surgery and on postoperative days one to three.  Facility-wide education was an important component in the successful implementation of this MRSA prophylaxis regimen. The hospital used standardized pre-signed physician order sets for the implementation of this protocol to ensure compliance. No other interventions were made during this time.

Facility-acquired MRSA SSIs among the non-general surgical population in this facility decreased by 72 percent during the study period, a statistically significant decline. The authors reported 19 fewer MRSA SSIs during the first year, and 26 fewer MRSA SSIs during the second year, representing a total of 1,035 fewer hospital days, prevention of 6 deaths, and cost savings of approximately $2,745,000.

This study adds to a growing research base indicating the importance of effective MRSA prophylaxis among surgical populations. 

Oral Abstract: Eliminating Annual Employee TST Testing: One Hospital’s Story (Publication 009, Presented by Jennifer Pruden, RN, CIC, Infection Preventionist, Hackettstown Regional Medical Center, at APIC Annual Conference 2013)

Reviewed by Carol McLay, RN, MPH, DrPH, CIC, Lexington, KY

Annual tuberculin skin testing (TST) of all employees in the acute care setting is a labor intensive task that requires many steps; including mailing out reminder memos, administering the TST, initial documentation, re-evaluation, and then final documentation. For staff members who require a second reminder letter, or forget to return for the reading, more time is required. 

The infection prevention team at this New Jersey healthcare facility analyzed five years of data and after reviewing the NJ State TB Risk Assessment guidelines and the 2005 CDC Guidelines for Preventing Transmission of M. tuberculosis in Health-care Settings, concluded that they were a low-risk facility for TB. Their hospital had no newly diagnosed TB patients, zero employee exposures, zero employee conversions, and a total of five TB patients for the entire county.

They contacted the NJ State TB Program Director to request a re-evaluation of their need for annual employee TB testing and in April 2012 received the approval to suspend their annual employee screening program. This decision was based on the historically low number of TB cases treated at the hospital, and the low probability of an exposure to undiagnosed TB due to low incidence in the community. Their TB Control Program Plan was modified to include: providing the initial two-step employee Mantoux Tuberculin Skin test for new hires, developing an annual employee TB symptom assessment completed with annual N95 mask fit testing and an expanded contact investigation procedure for any future exposures. The annual TST screening will resume if the criterion for “medium risk” be reached in any subsequent year.

Resources are being stretched to their limits due to growing state and federal mandates and reporting requirements. The author of this abstract concluded that facilities with a low risk for TB may benefit from re-examining tuberculosis data to determine if their annual TB practices can be safely modified.